פרק 10 Chapter 10: Pain in the Back, Neck, and Extremities Flashcards
Table 10-1
FEATURES OF THE MAIN Root compressive
SYNDROMES DUE TO CERVICAL AND LUMBAR DISC HERNIATION (4 cervical an 4 lumbar)
בת 25 , רזה מאוד מתלוננת על כאבים באזור גו עליון מימין וזרוע עליונה באותו הצד. מדווחת על שינויי
צבע באצבעות )מכחילות ומלבינות כאשר נחשפות למים קרים ואח”כ מאדימות(. בבדיקה נראה דלדול
קל של השרירים
hypothenar , interossei , adductor pollicis**
מהו הממצא האלקטרופיזיולוגי באותו הצד שמאפיין את פגיעתה?**
א. אמפליטודה ירודה של פוטנציאלים סנסורים של העצב האולנרי
ב. יחידות גדולות ופוליפזיות בשריר דלטואיד
ג. זמני חביון מוארכים של העצב הרדיאלי
ד. פיברילציות של השריר אבדוקטור פוליציס לונגוס
א. אמפליטודה ירודה של פוטנציאלים סנסורים של העצב האולנרי כחלק מ
Thoracic Outlet Syndromes (Superior Thoracic Aperture Syndrome
compression the brachial plexus, the subclavian artery, and the subclavian vein, causing muscle weakness and wasting, pain, and vascular abnormalities in the hand and arm.
majority of the patients have been young women with asthenic body habitus.
The anterior and middle scalene muscles, which flex and rotate the neck, are both inserted into the first rib so that the subclavian artery and vein and the brachial plexus must pass between them.
Three neurovascular syndromes :subclavian venous or arterial compression and a brachial plexopathy.
shoulder and arm pain is prominent. aching in the posterior hemithorax, pectoral region, and upper arm.
Compression or spontaneous thrombosis of the subclavian vein is a rare occurrence causing a dusky discoloration, venous distention, and edema of the arm.
Compression of the subclavian artery, which results in ischemia of the limb, may be complicated by digital gangrene and retrograde embolization
. A unilateral Raynaud phenomenon, brittle nails, and ulceration of the fingertips are important diagnostic findings. A supraclavicular bruit is suggestive The conventional tests for vascular compression—obliteration of the pulse when the patient, seated and with the arm extended, takes and holds a full breath, tilts the head back, and turns it to the affected side or abducts and externally rotates the arm and braces the shoulders and turns the head to either side are not entirely reliable.
a positive test only on the symptomatic side (with reproduction of the patient’s symptoms) is suggestive of the diagnosis of arterial compression and Slight wasting and weakness of the hypothenar, interosseous, adductor pollicis, and deep flexor muscles of the fourth and fifth fingers (i.e., the muscles innervated by the lower trunk of the brachial plexus and ulnar nerve).
Tendon reflexes are usually preserved.
most patients complain of an intermittent aching of the arm, particularly of the ulnar side, and about half of them complain also of numbness and tingling along the ulnar border of the forearm and hand
, nerve conduction studies disclose reduced amplitude of the ulnar sensory potentials.
decreased amplitude of the median motor evoked potentials
mild but uniform slowing of the median motor conduction velocity, and a prolongation of the F-wave latency.
Concentric needle examination of affected hand muscles reveals large-amplitude motor units, suggesting collateral reinnervation.
Common mistakes are to confuse the thoracic outlet syndrome with carpal tunnel syndrome, ulnar neuropathy or entrapment at the elbow, or cervical radiculopathy caused by arthritis or disc disease. Brachial neuritis may have a similar presentation. Imaging studies and careful nerve conduction and EMG studies may be necessary to exclude all of these disorders.
Figure 10-1.
A. The lumbar vertebrae viewed from above
B. from the side and
C. mid-sagittally.
A and B show the bony structures and their relationships to the disc space, facet joints and intervertebral foramina.
C demonstrates in a cutaway mid-sagittal view, the main ligamentous structures of the spine in relation to the bones and discs. The ligaments and articulations are critical to the mechanical integrity of the spinal column.
Figure 10-2.
(1) Costovertebral angle.
(2) Spinous process and interspinous
ligament.
(3) Region of articular facet (fifth lumbar to first
sacral).
(4) Dorsum of sacrum.
(5) Region of iliac crest.
(6) Iliolumbar angle.
(7) Spinous processes of fifth lumbar and first sacral vertebrae (tenderness = faulty posture or occasionally spina bifida occulta).
(8) Region between posterior superior and posteroinferior spines. Sacroiliac ligaments (tenderness = sacroiliac sprain, often tender, with fifth lumbar or first sacral disc).
(9) Sacrococcygeal junction (tenderness = sacrococcygeal injury; i.e., sprain or fracture).
(10) Region of sacrosciatic notch (tenderness = fourth or fifth lumbar disc rupture and sacroiliac sprain).
(11) Sciatic nerve trunk (tenderness = ruptured lumbar disc or sciatic nerve lesion).
Figure 10-3. Mechanisms of compression of the fifth lumbar and first sacral roots. A lateral disc protrusion at the L4-L5 level usually involves the fifth lumbar root and spares the fourth; a protrusion at L5-S1 involves the first sacral root and spares the fifth lumbar root. Note that a more medially placed disc protrusion at the L4-L5 level (cross-hatched) may involve the fifth lumbar root as well as the first (or second and third) sacral root.
Figure 10-4. Lumbar disc herniation as shown by T2-weighted MRI.
A. Sagittal view of a large herniated nucleus pulposus at L5-S1. The posteriorly protruding disc material indents and elevates the anterior thecal sac and narrows the spinal canal. The extruded material has the same signal characteristics of the parent disc. The disc space at this level is narrowed and the disc is less hyperintense than normal because of desiccation and the extruded component.
B. Axial view showing the focal right paracentral posterior disc herniation (large arrow) protruding into the canal and compressing the traversing nerve root (the right S1 nerve root) at this level. The exiting L5 roots above are not affected and can be seen laterally to the disc (small arrows).
Figure 10-5. Lumbosacral MRI of a patient with lymphoma, with radiation-induced arachnoiditis causing severe back pain and leg weakness.
A. Sagittal T2-weighted MRI showing clumping of the nerve roots of the cauda equina.
B. Axial T2-weighted image at the L3 vertebral level showing clumping of the nerve roots.
C. Axial T2-weighted image at the L5 vertebral level showing lateral displacement of nerve roots by acquired arachnoid cysts. There are bilateral metallic pedicle screws.
Figure 10-6. Cervical disc herniation as visualized with T2-weighted MRI.
A. Parasagittal view of a large posterior disc extrusion at C6-C7. Smaller broad-based posterior disc bulges are seen at C4-C5 and C5-C6.
B. Axial view of the large right posterolateral disc extrusion shown in (A) at C6-C7 (arrow) causing severe narrowing of the right neural foramen and compression of the exiting C7 nerve root.
C. By way of contrast, an axial view of the broad-based posterior disc bulge at C4-C5 (arrows) causes only minimal narrowing of the spinal canal and no compression of the spinal cord.
Figure 10-7. Course of the brachial plexus and subclavian artery between the anterior scalene and middle scalene muscles. Dilatation of the subclavian artery just distal to the anterior scalene muscle is illustrated. Immediately distal to the anterior and middle scalene muscles is another potential area of constriction, between the clavicle and the first rib. With extension of the neck and turning of the chin to the affected side (Adson maneuver), the tension on the anterior scalene muscle is increased and the subclavian artery compressed, resulting in a supraclavicular bruit and obliteration of the radial pulse.
