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Spinal Disorders- LeFebvre > 2a SMRs and Neuro orthos > Flashcards

2a SMRs and Neuro orthos Flashcards

1
Q

What family of nerves is being tested with the Achilles DTR? Which is primary?

A

S1 and S2, S1 is primary

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2
Q

What peripheral nerve is being tested with the Achilles DTR?

A

Sciatic nerve

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3
Q

What family of nerves are being tested with the patellar DTR? Which is primary?

A

L3 and L4, L4 is primary

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4
Q

What peripheral nerve is being tested with the patellar DTR?

A

Femoral nerve

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5
Q

What family of nerves is being tested with the hamstring DTR? Which is primary?

A

L5 and S1, L5 is primary

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6
Q

What peripheral nerve is being tested with the hamstring DTR?

A

Sciatic nerve

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7
Q

What muscle tests are used to check S1?

A
  • plantar flexion
  • ankle eversion
  • toe flexion
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8
Q

What family of nerve roots participate in toe flexion? Which is primary?

A

L4, L5, S1, S2, S3

S1 is primary

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9
Q

What peripheral nerve controls toe flexion?

A

Tibial nerve

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10
Q

What family of nerve roots participate in plantar flexion? Which is primary?

A

L4, L5, S1, S2, S3

Primary is S1

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11
Q

What peripheral nerve controls plantar flexion?

A

Tibial nerve

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12
Q

What family of nerve roots participate in ankle eversion? Which is primary?

A

L5, S1, S2

Primary is S1

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13
Q

What peripheral nerve is responsible for ankle eversion?

A

Perineal/fibularis nerve

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14
Q

What muscle tests are used to check L5?

A
  • big toe extension

- hip abduction

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15
Q

What family of nerve roots participate in big toe extension? Which is primary?

A

L5, S1

Primary is L5

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16
Q

What peripheral nerve is responsible to big toe extension?

A

Perineal nerve

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17
Q

What family of nerve roots participate in hip abduction? Which is primary?

A

L5, S1

Primary is L5

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18
Q

What peripheral nerve is responsible for hip abduction?

A

Superior gluteal nerve

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19
Q

What muscle tests are used to check L4?

A

Ankle dorsiflexion

Ankle inversion

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20
Q

What family of nerve roots participate in ankle dorsiflexion? Which is primary?

A

L4, L5, S1

Primary is L4

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21
Q

What family of nerve roots participate ankle inversion? Which is primary?

A

L4, L5, S1

Primary is L4

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22
Q

What peripheral nerve is responsible for ankle dorsiflexion?

A

Deep peroneal/fibular nerve

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23
Q

What peripheral nerve is responsible for ankle inversion?

A

Deep peroneal/fibular nerve

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24
Q

What is the typical finding of nerve tension tests with radicular syndrome?

A

Often reproduces leg symptoms

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25
Q

What is the purpose of a nerve tension test?

A

To provoke inflamed peripheral nerve or its roots for diagnostic purposes

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26
Q

SLR is the pain tension test for which nerve roots and peripheral nerve?

A

L4, L5, S1

Sciatic nerve

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27
Q

What is a hard positive SLR test?

A

Creating or aggravating lower extremity pain past the knee

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28
Q

What is a soft positive SLR test?

A

Creating or aggravating lower extremity pain above the knee

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29
Q

SLR is a very sensitive test for what diagnosis?

A

Posterolateral disc herniation (good at ruling out if SLR is negative)

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30
Q

SLR has good sensitivity for posterolateral disc derivations but poor sensitivity for 3 other differential diagnoses. What are they?

A

Spinal stenosis
Spondylolisthesis
Midline and medial disc herniations

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31
Q

When would you use Braggards, Bowstring and Bonnets muscle tension tests?

A

To confirm the results of a positive SLR

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32
Q

How is a maximum SLR different from and SLR?

A

Maximum SLR incorporates dorsiflexion of the foot, internal rotation of the leg and neck flexion to maximally stretch the nerves

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33
Q

What is the advantage of doing a seated SLR over and standard SLR?

A

The IVD is loaded

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34
Q

What is another name for the seated SLR?

A

Bechetrew

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35
Q

What is the slump test?

A

Is the maximum seated SLR so there is IVD loading, dorsiflexion of foot, internal rotation of leg, flexion of head

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36
Q

What nerve roots are being stretched with the reverse SLR? What peripheral nerve?

A

L2, L3, L4

Femoral nerve

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37
Q

What is the expected finding with spinal loading in radicular syndrome?

A

Rapid reproduction of leg symptoms

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38
Q

What are 3 examples of ways to cause spinal loading?

A
  • Valsalva maneuver
  • Kemp’s test (leg extension and ipsilateral rotation)
  • forward flexion
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39
Q

If the physical exam produces neuropathic findings, what must be figured out next?

A
  • which root(s) involved
  • nature and degree of nerve root injury
  • cause of injury
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40
Q

An inflamed nerve root is called ______

A

Radiculitis

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41
Q

A compressed or torn nerve root is called ______

A

Radiculopathy

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42
Q

Increased sensitivity would be characteristics of what nerve root condition?

A

Radiculitis

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43
Q

Sensory loss would be characteristic of what nerve root condition?

A

Radiculopathy

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44
Q

Which would present with motor deficits, radiculitis or radiculopathy?

A

Radiculopathy

45
Q

Which would have a positive SLR, radiculitis or radiculopathy?

A

Radiculitis

46
Q

Which would have a positive Kemps test, radiculitis or radiculopathy?

A

Radiculitis

47
Q

What are the top 2 causes of Cauda equina syndrome?

A

Large midline disc herniation

Severe spinal stenosis

48
Q

What are the three less common causes of cauda equina syndrome?

A

Tumor
Infection
Hematoma

49
Q

What bladder changes are associated with CES?

A

Urinary retention and urinary incontinence

50
Q

What bowel changes are associated with CES?

A
  • Inability control defecation due to decreased anal sphincter tone
  • Sense of rectal fullness
51
Q

What are the two most common symptoms associated with CES in order of prevalence?

A

Urinary dysfunction

Saddle hypesthesia

52
Q

What sexual dysfunction is associated with CES?

A

Decreased penile/labial sensation
Inability to get or maintain an erection
Reduced arousal of clitoris

53
Q

How quickly after neurological compromise to symptoms occur in CES?

A

Less than 24 hours

54
Q

What are other findings that may be incidentally found in CES?

A

Unilateral or bilateral sciatica

Positive SLR

55
Q

What neuropathy can mimic CES?

A

Pudendal nerve lesion AKA Alcock’s syndrome

56
Q

What are 3 findings from the history that could help distinguish between CES and Alcock’s syndrome?

A

Alcock’s is aggravated by sitting while CES is not
Back pain is common in CES but not Alcock’s
Alcock’s is often related to a fall on the buttock, traction injury or vigorous bicycling

57
Q

What 4 peripheral nerves commonly cause leg pain?

A
  • femoral
  • lateral femoral cutaneous
  • sciatic nerve
  • common peroneal
58
Q

What are the two mechanisms of peripheral nerve lesions?

A
  • entrapment/compression

- disease (polyneuropathy)

59
Q

What are the three most common diseases associated with neuropathy in order of prevalence?

A
  • diabetes
  • alcoholic neuropathy
  • vitamin B12 deficiency
60
Q

What quality of leg pain is more more indicative of neuropathy than radiculopathy?

A

Burning

61
Q

Describe leg paresthesia associated with neuropathy?

A

Usually present and in a peripheral nerve territory (“stocking and glove” distribution

62
Q

What are the typically findings of SMR testing with neuropathy?

A

May be one or more deficit or hypersensitivity corresponding to the same peripheral nerve

63
Q

What would be the findings with a nerve tension test if there was neuropathy?

A

Often reproduces leg symptoms

64
Q

What would be the findings of spinal loading procedures if there was neuropathy?

A

Usually does not reproduce leg symptoms

65
Q

What nerve roots are associated with the femoral nerve?

A

L2, L3, L4

66
Q

What is the most common cause of femoral neuropathy?

A

Diabetes mononeuropathy

67
Q

Other than diabetes, what are other possible causes of femoral neuropathy?

A

Compression of the femoral nerve inside the pelvis from a tumor or psoas/iliacus hematoma following trauma (complicated by anticoagulants)

68
Q

What antalgic position might a patient with femoral neuropathy take?

A

Hip flexion because it puts slack on the femoral nerve

69
Q

Describe the femoral nerve sensory territory

A

Groin

Anteriomedial thigh, knee and calf

70
Q

What muscle groups are innervated by the femoral nerve and therefore symptomatic with femoral neuropathy?

A
  • hip flexors (iliopsoas)
  • knee extensors (quadriceps)

NOTE: all muscles are above the knee whereas sensory innervation of femoral nerve goes below the knee

71
Q

Sudden knee buckling may be the initial symptom when what nerve is compressed?

A

Femoral

72
Q

What is a good (sensitive) muscle test for the quadriceps?

A

Single leg rise from a chair

73
Q

Femoral nerve compression and L3 nerve root compression can have overlapping symptoms. What is one distinguishing physical exam finding?

A

Adductor weakness which are controlled by the lumbosacral plexus (L2-L4) via obturator nerve but not femoral nerve

74
Q

What is the cutaneous innervation territory for the obturator nerve?

A

Oval patch on the medial aspect of the middle thigh

75
Q

What would a decreased of absent patellar reflex indicate?

A

There may be quadriceps muscle atrophy from femoral neuropathy or L4 radiculopathy

76
Q

What would a positive femoral stretch test be?

A

Creates sharp anterior thigh pain

77
Q

In diabetic neuropathy, what usually comes first, muscle weakness or sensory changes?

A

Sensory changes

78
Q

Painful femoral nerve pain should be followed up with what ancillary tests?

A

Hgb-A1c and fasting glucose

79
Q

What is the threshold for glycosylation of Hgb?

A

Depends on the source but it ranges from 5% to 7%

80
Q

What is the threshold for fasting glucose?

A

126 mg

81
Q

What does the “classic” diabetic peripheral neuropathy look like?

A
  • bilateral, symmetric polyneuropathy
  • sensory loss being is feet and then hands
  • tends to cause burning pain
  • can cause allodynia
82
Q

What ancillary studies can be done (although they rarely are) to further differentiate where a peripheral nerve lesion is and what is causing it?

A
  • EMG and nerve conduction study to differentiate lesion

- CT to rule out mass

83
Q

What are the treatments for femoral neuropathy?

A

It depends on what the cause is:

  • treat diabetes
  • remove tumor or hematoma
  • can spontaneously resolve if secondary to surgical procedure
84
Q

What two conditions has evidence show pain relief with the use of Gabapentin?

A
  • diabetic neuropathy

- Postherpetic neuralgia

85
Q

What neuropathy is characterized by anterolateral thigh sensory changes but no motor involvement?

A

Meralgia paresthetica (AKA lateral femoral cutaneous neuropathy)

86
Q

What are some common pathophysiology in meralgia paresthetica?

A
  • entrapment of the nerve as it passes the inguinal ligament

- this can happen from wearing tight pants, obesity, pregnancy, diabetes, trauma or extended cycling

87
Q

What are the most common causes of peroneal nerve entrapment?

A

External compression or stretching of the nerve near the fibular head from:

  • postural factors such as crossing legs, prolonged squatting, etc.
  • repetitive motions such as running
  • weight loss
  • trauma
  • iatrogenic from cast, tight bandages or malpositioning during anesthesia
88
Q

What are the common characteristics of peroneal nerve entrapment presentation?

A
  • pain is uncommon but when present is local and radiates up thigh
  • foot drop is often primary presentation and may be partial or complete
  • L4, L5, S1 muscle testing may have weakness
  • paresthesia may be present over the lateral lower leg and dorsum of foot
  • forced inversion can stretch nerve and increase pain
  • Achilles reflex is usually normal
89
Q

Are cord problems commonly associated with LBP?

A

No, because there is no cord past L1/L2 but it can

90
Q

Although all are rare, what are the 4 most common causes of myelopathy/cord compression in the lumbar spine?

A
  • upper disc lesion/herniation
  • spinal canal stenosis
  • compression fracture at TLJ
  • tumor or other SOL
91
Q

Besides leg pain, what are symptoms could indicate spinal cord involvement in the lumbar spine?

A
  • urinary incontinence
  • constipation
  • impotence

NOTE: these are the same as CES but come from cord compression, not NR compression

92
Q

What findings would be present on neurologic exam if there were cord compression (UMNL) in the lumbar spine?

A
  • hyperreflexia
  • positive Babinski
  • positive clonus
  • loss of cremasteric reflex
  • positive Romberg’s test
93
Q

Positive Romberg’s test would be found in what 5 conditions/lesions?

A
  • myelopathy
  • neuropathy
  • radiculopathy
  • cerebellar disease
  • vestibular disorder
94
Q

What are three diseases that affect the dorsal column and can result in a positive Romberg’s test?

A

Vitamin B12 deficiency
Neurosyphillis (tabes dorsalis)
Non-syphilitic sensory neuropathies

95
Q

A lesion of the dorsal column will result in what kind of sensory deficits?

A

Ipsilateral deficits below the lesion:

  • loss of proprioception
  • loss of vibration
  • loss of fine touch
  • loss of 2 point discrimination

Mnemonic: PVT 2

96
Q

Lesion of the lateral spinothalamic tract results in what sensory deficit?

A

Contralateral loss of:

  • pain/nociception
  • temperature sensation
97
Q

What are pertinent negative findings with an UMNL?

A

No fasciculations or fibrillations

No significant muscle atrophy

98
Q

Describe the leg pain that may be present with lumbar myelopathy?

A

Only sometimes present
Non dermatomal and generalized
Often described as burning
Back pain is usually worse than leg pain

99
Q

Describe leg paresthesia that may be present with lumbar myelopathy

A

Sometimes present
Non dermatomal
Described as numbness

100
Q

What would the results of a nerve tension test be with myelopathy?

A

Negative

101
Q

Are the symptoms of lumbar myelopathy affected by spinal loading procedures?

A

No

102
Q

How is the diagnosis of deep referred back and leg pain made?

A

By excluding neuropathic causes of back and leg pain and primary on negative test results

  • rarely paresthesia
  • normal SMRs
  • negative tension tests
  • negative spinal loading
103
Q

Which is worse with deep referred pain, back or leg pain?

A

Back pain is usually worse

104
Q

What type of nerve injury/lesion is associated with more evident muscle atrophy?

A

Peripheral neuropathy

105
Q

Burning pain is associated with what kind of nerve injury/lesion?

A

Peripheral neuropathy or occasionally myelopathy

NOT radicular

106
Q

A vibration deficit is most common in what kind of disease of the nerve?

A

Diabetic neuropathy

107
Q

A deficit in the detection of cold would imply what kind of nerve injury/lesion?

A

Radiculopathy

108
Q

A positive straight leg raise test would imply what kind of nerve injury/lesion?

A

Radiculopathy

109
Q

An abnormal response to pinprick would most likely imply what kind of nerve injury/lesion?

A

Neuropathy

Spinal Disorders- LeFebvre (25 decks)

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