2a SMRs and Neuro orthos Flashcards
What family of nerves is being tested with the Achilles DTR? Which is primary?
S1 and S2, S1 is primary
What peripheral nerve is being tested with the Achilles DTR?
Sciatic nerve
What family of nerves are being tested with the patellar DTR? Which is primary?
L3 and L4, L4 is primary
What peripheral nerve is being tested with the patellar DTR?
Femoral nerve
What family of nerves is being tested with the hamstring DTR? Which is primary?
L5 and S1, L5 is primary
What peripheral nerve is being tested with the hamstring DTR?
Sciatic nerve
What muscle tests are used to check S1?
- plantar flexion
- ankle eversion
- toe flexion
What family of nerve roots participate in toe flexion? Which is primary?
L4, L5, S1, S2, S3
S1 is primary
What peripheral nerve controls toe flexion?
Tibial nerve
What family of nerve roots participate in plantar flexion? Which is primary?
L4, L5, S1, S2, S3
Primary is S1
What peripheral nerve controls plantar flexion?
Tibial nerve
What family of nerve roots participate in ankle eversion? Which is primary?
L5, S1, S2
Primary is S1
What peripheral nerve is responsible for ankle eversion?
Perineal/fibularis nerve
What muscle tests are used to check L5?
- big toe extension
- hip abduction
What family of nerve roots participate in big toe extension? Which is primary?
L5, S1
Primary is L5
What peripheral nerve is responsible to big toe extension?
Perineal nerve
What family of nerve roots participate in hip abduction? Which is primary?
L5, S1
Primary is L5
What peripheral nerve is responsible for hip abduction?
Superior gluteal nerve
What muscle tests are used to check L4?
Ankle dorsiflexion
Ankle inversion
What family of nerve roots participate in ankle dorsiflexion? Which is primary?
L4, L5, S1
Primary is L4
What family of nerve roots participate ankle inversion? Which is primary?
L4, L5, S1
Primary is L4
What peripheral nerve is responsible for ankle dorsiflexion?
Deep peroneal/fibular nerve
What peripheral nerve is responsible for ankle inversion?
Deep peroneal/fibular nerve
What is the typical finding of nerve tension tests with radicular syndrome?
Often reproduces leg symptoms
What is the purpose of a nerve tension test?
To provoke inflamed peripheral nerve or its roots for diagnostic purposes
SLR is the pain tension test for which nerve roots and peripheral nerve?
L4, L5, S1
Sciatic nerve
What is a hard positive SLR test?
Creating or aggravating lower extremity pain past the knee
What is a soft positive SLR test?
Creating or aggravating lower extremity pain above the knee
SLR is a very sensitive test for what diagnosis?
Posterolateral disc herniation (good at ruling out if SLR is negative)
SLR has good sensitivity for posterolateral disc derivations but poor sensitivity for 3 other differential diagnoses. What are they?
Spinal stenosis
Spondylolisthesis
Midline and medial disc herniations
When would you use Braggards, Bowstring and Bonnets muscle tension tests?
To confirm the results of a positive SLR
How is a maximum SLR different from and SLR?
Maximum SLR incorporates dorsiflexion of the foot, internal rotation of the leg and neck flexion to maximally stretch the nerves
What is the advantage of doing a seated SLR over and standard SLR?
The IVD is loaded
What is another name for the seated SLR?
Bechetrew
What is the slump test?
Is the maximum seated SLR so there is IVD loading, dorsiflexion of foot, internal rotation of leg, flexion of head
What nerve roots are being stretched with the reverse SLR? What peripheral nerve?
L2, L3, L4
Femoral nerve
What is the expected finding with spinal loading in radicular syndrome?
Rapid reproduction of leg symptoms
What are 3 examples of ways to cause spinal loading?
- Valsalva maneuver
- Kemp’s test (leg extension and ipsilateral rotation)
- forward flexion
If the physical exam produces neuropathic findings, what must be figured out next?
- which root(s) involved
- nature and degree of nerve root injury
- cause of injury
An inflamed nerve root is called ______
Radiculitis
A compressed or torn nerve root is called ______
Radiculopathy
Increased sensitivity would be characteristics of what nerve root condition?
Radiculitis
Sensory loss would be characteristic of what nerve root condition?
Radiculopathy
Which would present with motor deficits, radiculitis or radiculopathy?
Radiculopathy
Which would have a positive SLR, radiculitis or radiculopathy?
Radiculitis
Which would have a positive Kemps test, radiculitis or radiculopathy?
Radiculitis
What are the top 2 causes of Cauda equina syndrome?
Large midline disc herniation
Severe spinal stenosis
What are the three less common causes of cauda equina syndrome?
Tumor
Infection
Hematoma
What bladder changes are associated with CES?
Urinary retention and urinary incontinence
What bowel changes are associated with CES?
- Inability control defecation due to decreased anal sphincter tone
- Sense of rectal fullness
What are the two most common symptoms associated with CES in order of prevalence?
Urinary dysfunction
Saddle hypesthesia
What sexual dysfunction is associated with CES?
Decreased penile/labial sensation
Inability to get or maintain an erection
Reduced arousal of clitoris
How quickly after neurological compromise to symptoms occur in CES?
Less than 24 hours
What are other findings that may be incidentally found in CES?
Unilateral or bilateral sciatica
Positive SLR
What neuropathy can mimic CES?
Pudendal nerve lesion AKA Alcock’s syndrome
What are 3 findings from the history that could help distinguish between CES and Alcock’s syndrome?
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
What 4 peripheral nerves commonly cause leg pain?
- femoral
- lateral femoral cutaneous
- sciatic nerve
- common peroneal
What are the two mechanisms of peripheral nerve lesions?
- entrapment/compression
- disease (polyneuropathy)
What are the three most common diseases associated with neuropathy in order of prevalence?
- diabetes
- alcoholic neuropathy
- vitamin B12 deficiency
What quality of leg pain is more more indicative of neuropathy than radiculopathy?
Burning
Describe leg paresthesia associated with neuropathy?
Usually present and in a peripheral nerve territory (“stocking and glove” distribution
What are the typically findings of SMR testing with neuropathy?
May be one or more deficit or hypersensitivity corresponding to the same peripheral nerve
What would be the findings with a nerve tension test if there was neuropathy?
Often reproduces leg symptoms
What would be the findings of spinal loading procedures if there was neuropathy?
Usually does not reproduce leg symptoms
What nerve roots are associated with the femoral nerve?
L2, L3, L4
What is the most common cause of femoral neuropathy?
Diabetes mononeuropathy
Other than diabetes, what are other possible causes of femoral neuropathy?
Compression of the femoral nerve inside the pelvis from a tumor or psoas/iliacus hematoma following trauma (complicated by anticoagulants)
What antalgic position might a patient with femoral neuropathy take?
Hip flexion because it puts slack on the femoral nerve
Describe the femoral nerve sensory territory
Groin
Anteriomedial thigh, knee and calf
What muscle groups are innervated by the femoral nerve and therefore symptomatic with femoral neuropathy?
- hip flexors (iliopsoas)
- knee extensors (quadriceps)
NOTE: all muscles are above the knee whereas sensory innervation of femoral nerve goes below the knee
Sudden knee buckling may be the initial symptom when what nerve is compressed?
Femoral
What is a good (sensitive) muscle test for the quadriceps?
Single leg rise from a chair
Femoral nerve compression and L3 nerve root compression can have overlapping symptoms. What is one distinguishing physical exam finding?
Adductor weakness which are controlled by the lumbosacral plexus (L2-L4) via obturator nerve but not femoral nerve
What is the cutaneous innervation territory for the obturator nerve?
Oval patch on the medial aspect of the middle thigh
What would a decreased of absent patellar reflex indicate?
There may be quadriceps muscle atrophy from femoral neuropathy or L4 radiculopathy
What would a positive femoral stretch test be?
Creates sharp anterior thigh pain
In diabetic neuropathy, what usually comes first, muscle weakness or sensory changes?
Sensory changes
Painful femoral nerve pain should be followed up with what ancillary tests?
Hgb-A1c and fasting glucose
What is the threshold for glycosylation of Hgb?
Depends on the source but it ranges from 5% to 7%
What is the threshold for fasting glucose?
126 mg
What does the “classic” diabetic peripheral neuropathy look like?
- bilateral, symmetric polyneuropathy
- sensory loss being is feet and then hands
- tends to cause burning pain
- can cause allodynia
What ancillary studies can be done (although they rarely are) to further differentiate where a peripheral nerve lesion is and what is causing it?
- EMG and nerve conduction study to differentiate lesion
- CT to rule out mass
What are the treatments for femoral neuropathy?
It depends on what the cause is:
- treat diabetes
- remove tumor or hematoma
- can spontaneously resolve if secondary to surgical procedure
What two conditions has evidence show pain relief with the use of Gabapentin?
- diabetic neuropathy
- Postherpetic neuralgia
What neuropathy is characterized by anterolateral thigh sensory changes but no motor involvement?
Meralgia paresthetica (AKA lateral femoral cutaneous neuropathy)
What are some common pathophysiology in meralgia paresthetica?
- entrapment of the nerve as it passes the inguinal ligament
- this can happen from wearing tight pants, obesity, pregnancy, diabetes, trauma or extended cycling
What are the most common causes of peroneal nerve entrapment?
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
What are the common characteristics of peroneal nerve entrapment presentation?
- 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
Are cord problems commonly associated with LBP?
No, because there is no cord past L1/L2 but it can
Although all are rare, what are the 4 most common causes of myelopathy/cord compression in the lumbar spine?
- upper disc lesion/herniation
- spinal canal stenosis
- compression fracture at TLJ
- tumor or other SOL
Besides leg pain, what are symptoms could indicate spinal cord involvement in the lumbar spine?
- urinary incontinence
- constipation
- impotence
NOTE: these are the same as CES but come from cord compression, not NR compression
What findings would be present on neurologic exam if there were cord compression (UMNL) in the lumbar spine?
- hyperreflexia
- positive Babinski
- positive clonus
- loss of cremasteric reflex
- positive Romberg’s test
Positive Romberg’s test would be found in what 5 conditions/lesions?
- myelopathy
- neuropathy
- radiculopathy
- cerebellar disease
- vestibular disorder
What are three diseases that affect the dorsal column and can result in a positive Romberg’s test?
Vitamin B12 deficiency
Neurosyphillis (tabes dorsalis)
Non-syphilitic sensory neuropathies
A lesion of the dorsal column will result in what kind of sensory deficits?
Ipsilateral deficits below the lesion:
- loss of proprioception
- loss of vibration
- loss of fine touch
- loss of 2 point discrimination
Mnemonic: PVT 2
Lesion of the lateral spinothalamic tract results in what sensory deficit?
Contralateral loss of:
- pain/nociception
- temperature sensation
What are pertinent negative findings with an UMNL?
No fasciculations or fibrillations
No significant muscle atrophy
Describe the leg pain that may be present with lumbar myelopathy?
Only sometimes present
Non dermatomal and generalized
Often described as burning
Back pain is usually worse than leg pain
Describe leg paresthesia that may be present with lumbar myelopathy
Sometimes present
Non dermatomal
Described as numbness
What would the results of a nerve tension test be with myelopathy?
Negative
Are the symptoms of lumbar myelopathy affected by spinal loading procedures?
No
How is the diagnosis of deep referred back and leg pain made?
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
Which is worse with deep referred pain, back or leg pain?
Back pain is usually worse
What type of nerve injury/lesion is associated with more evident muscle atrophy?
Peripheral neuropathy
Burning pain is associated with what kind of nerve injury/lesion?
Peripheral neuropathy or occasionally myelopathy
NOT radicular
A vibration deficit is most common in what kind of disease of the nerve?
Diabetic neuropathy
A deficit in the detection of cold would imply what kind of nerve injury/lesion?
Radiculopathy
A positive straight leg raise test would imply what kind of nerve injury/lesion?
Radiculopathy
An abnormal response to pinprick would most likely imply what kind of nerve injury/lesion?
Neuropathy
