5.5 Clinical - Regional Back Pain Scheme Wrap-Up Flashcards
A 65-year-old was on vacation, while driving, he was struck from behind by a driver in a Lamborghini at a high rate of speed. He was wearing his seat belt, and his air bags deployed. He was brought to the ER, where you are stationed. The patient was initially stunned, and now complains of neck pain, comes in with c-spine support.
What is the first thing you do?
Order X-ray.
Where on the Regional Back Pain scheme are we? (cervical, thoracic, lumbar/sacral)(acute or chronic)(infectious, neurological, MSK, vasc)?
Cervical.
Acute.
MSK.
The male underwent a whiplash injury. What would be another very important test to use in order to understand the severity of this whiplash injury? (What can be commonly injured during these types of injuries and lead to bigger issues).
Neurologic exam to test for any nerve impingement.
When ordering images for whiplash injuries, the American College of Radiology has some guidelines. What type of images COULD you obtain and which would you not? In those that you would obtain what would they help you determine?
X-ray is done to rule out bony fracture.
Motion CT CAN show ligamentous injury.
MRI validity in upper cervical spine ligaments to detect actue whiplash injury has NOT been demonstrated.
Someone presents to you with cervical spine trauma from hyperextension of the neck.
History: They have severe pain, spasm, and tenderness. They also have radiating arm pain and global sensory and motor deficits.
Physical: swelling, bruising, tenderness/spasm to touch, step off sign.
What is going on here? What would you order, what would you perform, what would you suspect?
Order an x-ray to look for fracture (suspected).
Suspect nerve impingement, probably perform neural exam.
What is a severe injury of hyperextension, hyperflexion, or lateral flexion that has a high mortality rate? What does it affect (anatomically)? Why is it so severe, what does it result in? What are 2 imaging techniques used to visualize this, and what do they allow you to visualize?
Occipito-Atlanto Dislocation (OAD).
Affects ligaments, results in ligamentous instability.
Can result in paresis and apnea.
X-ray or Motion CT allow you to see abnormalities in joint motion or articulation.
History: Young pt presents w/ abnormal upper extremity neurologic exam. Paravertebral neck pain, relieved by rest and worsened by activity.
Physical: Arm pain w/ cervical ROM. Abnormal sensory or motor nerve tests.
Negative x-ray for fracture.
What is going on here neurologically, what is the etiology?
Cervical radiculopathy.
Herniated cervical disc.
What is radiculopathy (just explain it to yourself and I will give ya the definition)? Common causes (2)?
Radiculopathy: nerve root compression at neck w/ resultant pain, tingling, and numbness, w/ or w/o loss of function in area supplied by affected nerve.
Common causes: neural foraminal narrowing, from cervical arthritis in older adults. Cervical disk lesion (disk degeneration or disk herniation).
Both of these ^ lead to stenosis (narrowing of vertebral cavity).
Cervical radiculopathy can result in what musculoskeletally (near, far)? Result in what regarding ROM? What regarding AP curves?
Neck stiffness, paresthesias of fingers, weakness in extremity, pain radiating to shoulder/ upper extremity.
Reduced ROM.
Reduced lordosis.
Pt presents with bilateral arm pain, weakness of hands and legs, clumsiness, disequilibrium, urinary dysfunction, paraspinal tenderness, electric shocks with cervical flexion, upper and lower extremity motor or sensory dysfunction.
What is going on here? What helps you differentiate this between another very similar diagnosis (what is that diagnosis)?
This is Cervical Myelopathy. Spinal cord impingement.
Bilateral, involving upper/ lower extremities, global problems (urinary, disequilibrium, clumsiness). These are typical of myelopathy due to the entire spinal cord being impinged. Radiculopathy is similar however, it would be unilateral due to only the NERVE ROOT being impinged.
Pt presents with headaches in occiptal region, they say they can “hear their heart beat” in their ear, they have cranial nerve palsies on physical exam.
What is the problem here? What would you be able to hear by listening to the affected area?
Vertebral artery insufficiency.
You could hear bruit (swooshing) sounds by listening to the vertebral arteries.
Pt. presents with vertigo, unilateral facial paresthesia, cerebellar signs, vision blurry, Hx of motor vehicle accident at 55mph.
What is the occurring? How can you tell?
Anterior cervical artery insufficiency.
Severe whiplash (hyperextension/ flexion) would injury these arteries.
I don’t know anything else so add if you can.
48 year old male presents to the Emergency Department with thoracic pain of unknown origin, which started 6 hours ago. He complains also of slight chest pressure and slight nausea. He has no recent history of trauma.
History: hypertension, hypercholesterolemia, chest pain, left arm pain, nausea, onset symptoms w/ exertion, pale, diaphoretic appearance.
What is your next move? Why would you do that?
Get EKG ASAP, blood.
Possible HA or thoracic aortic aneurysm.
Your last patient who is HA susceptible and you got the EKG and bloodwork done. What would you expect to see if he is in fact having a heart attack?
EKG: ST segment elevation.
CK enzyme elevation.
Troponin 1 elevation.
Pt. presents to you with thoracic back pain acutely, upon taking their vitals you find they are hypotensive.
What next?
Get your cardiothoracic surgical team ready and get this dude an OR because he is most likely about to have an Thoracic Aortic Aneurism Rupture.
While the team is assembling you MAY get a bedside EKG if you aren’t sure, but if you suspect and he is hypotensive enough, don’t mess around.
This may be found on CT or MRI when looking for something else.
A 60 year old female presents to the office with severe lower back pain, which has been increasing over the past 10 days.
History: She also complains of intermittent fever, chills, malaise, and a lack of appetite, which has been slowly worsening over the past week.
Physical: hyperemia and swelling over area, restricted motion, tenderness, no neuro deficits, vitals positive for fever.
What do you suspect? What are you going to get done in order to verify? What are the red flags?
Please appreciate the workup of this, on the test they may tell you the first paragraph presenting info, then ask what would you do next? (get HPI right!)
Osteomyelitis (infection).
Get MRI to inspect (will show high density bright areas where infection lays).
Red flags: swelling, fever, chills, sweats, recent surgery (if applicable), night pain.
Same workup as last pt.
Give another differential? Prior to imaging.
Diskitis.
