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LeFebvre > B11 Cervical Neuro Assessment > Flashcards

B11 Cervical Neuro Assessment Flashcards

1
Q

What are the 5 main clues for NR lesions in the cervical spine?

A
  • pain in arm
  • paresthesia in arm
  • SMR deficits in arm
  • cervical orthopedic tests change arm symptoms
  • AROM and loading c-spine reproduce arm symptoms
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2
Q

What are the 4 main questions from the history about arm pain when radicular syndrome is suspected?

A
  • location (sometimes dermatomal and past elbow, superficial)
  • quality (sharp, stabbing)
  • severity (arm>neck)
  • affected by spinal position (aggravates)
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3
Q

Describe the arm pain associated with radicular syndrome?

A

Classic presentation is often NOT seen. The pain is often diffuse and poorly localized, rarely dermatomal (53.9%)

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4
Q

Describe the arm paresthesia associated with radicular syndrome.

A
  • starts distal and spread proximal

- more dermatomal than pain

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5
Q

How do you predict which NR is affected in cervical radiculopathy?

A

Deficits and paresthesia distribution is more predictive than pain distribution

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6
Q

Where is the C5 pure patch?

A

Deltoid tubercle

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7
Q

Where is the C6 pure patch?

A

Thumb web on dorsal aspect of thumb

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8
Q

Where is the pure patch for C8?

A

Medial tip of 5th digit

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9
Q

What is the +LR associated with the C6 pure patch?

A

8.5

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10
Q

What is the +LR associated with the C8 pure patch?

A

41.8

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11
Q

What is the pure patch for axillary nerve?

A

Deltoid tubercle

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12
Q

What is the pure patch for radial nerve?

A

Thumb wed of dorsal aspect

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13
Q

What is the pure patch for median nerve?

A

Lateral tip of index finger

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14
Q

What is the pure patch for ulnar nerve?

A

Medial tip of 5th digit

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15
Q

What motor testing is done for C5?

A

Shoulder abduction

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16
Q

What motor testing is done for C6

A

Elbow flexion
Wrist extension
Pronation

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17
Q

What motor testing is done for C7?

A

Elbow extension
Wrist flexion
Finger extension
Pronation

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18
Q

What motor testing is done for C8?

A

Finger flexion

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19
Q

What motor testing is done for T1?

A

Dorsal interossei finger abduction

Palmar interossei finger adduction

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20
Q

Of the muscle tests available for C6 radiculopathies, which is most commonly weak?

A

Pronation

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21
Q

Why is is important to muscle test pronation in patients with suspected radiculopathy?

A
  • It is the most common weakness in C6 radics

- in some cases of C7 radiculopathy,it is the only muscle with weakness

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22
Q

What is the DTR for C5?

A

Biceps reflex

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23
Q

What is the DTR for C6?

A

Brachioradialis relfex

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24
Q

What is the DTR for C7?

A

Triceps reflex

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25
Q

All all of the SMRs for C6, which has the highest positive LR and therefore is the more predictive of C6 radiculopathy?

A

Decrease in brachioradialis (or biceps) reflex (14.2)

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26
Q

All all of the SMRs for C7, which has the highest positive LR and therefore is the more predictive of C7 radiculopathy?

A

Decrease in triceps reflex (28.3)

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27
Q

All all of the SMRs for C8, which has the highest positive LR and therefore is the more predictive of C8 radiculopathy?

A

Sensory loss on medial aspect of little finger (41.2)

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28
Q

What is a prolonged contraction of a particular muscle or increased muscle tone that results in abnormal posturing or a muscle spasm. Often painful and debilitating

A

Dystonia

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29
Q

What is a rhythmic contraction of large muscle groups, often described as a rolling or writhing motion, sometimes can be smaller ticks as well. Usually not painful

A

Dyskinesia

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30
Q

What are the big 5 cervical orthopedic tests?

A 
Cervical compression
Cervical distraction
Shoulder abduction
Upper limb tension tests (median n.)
Valsalva maneuver
31
Q

What are the three versions of cervical compression that should be done in orthopedic testing?

A

Neutral
Lateral flexion
Maximum

32
Q

A positive maximum compression (aka spurling’s test) is evidence for what two conditions?

A

Radicular lesion
Disc herniation in cervical spine

NOTE: negative test does not rule out disc

33
Q

What is the + LR of cervical distraction improving arm symptoms?

A

4.4

34
Q

Improvement in arm symptoms with shoulder abductions is evidence for what two conditions?

A

Radicular lesion

Disc herniation

35
Q

What is Bakody’s sign?

A

Patient presenting with arm held about head for symptom reduction

36
Q

What does a positive median nerve tension test suggest?

A

Irritation in the NR but it is not specific. Could be irritated NR, brachial plexus or median n.

37
Q

Aggravation of symptoms with Valsalva is evidence for what conditions?

A

Radicular lesion
Disc herniation
SOL

38
Q

Of the 5 cervical orthopedic tests, which is the only one good at ruling out radicular lesion (i.e. high sensitivity)?

A

ULTT-median

39
Q

What positions cause compression of the IVF?

A

Extension
Ipsilateral rotation
Ipsilateral lateral flexion

Therefore flexion, contralateral rotation and lateral flexion will increase the size of the IVF

40
Q

Since Kemp’s and quadrant position can aggravate symptoms of facet syndrome and NR lesions, who can you distinguish between the two.

A

If symptoms are immediately aggravated, think NR lesion. If position must be held to elicit worsening of symptoms, think facet syndrome

41
Q

If lateral bending of the cervical spine reproduces arm symptoms, what is your first and second DDX?

A 
1st = brachial plexopathy
2nd = NR lesion
42
Q

What is the doorbell sign?

A

Pressing on medial border of SCM toward NRs recreates pain

43
Q

What is the classic doorbell positive and what does it indicate?

A

Recreating pain between the shoulder blades

Indicates cervical referred pain

44
Q

What is the alternate doorbell positive and what does it indicate?

A

Recreation of arm symptoms

Indicates cervical nerve root pain

45
Q

What cluster of tests, when 3/4 are positive have a 65% post-test probability and when 4/4 are positive have a post test probability of 90% for radiculopathy in the cervical spine?

A

ULLT - median nerve
Cervical rotation <60 to symptomatic side
Distraction
Modified Spurling (aka max cervical compression)

46
Q

Describe the pain pattern of cervical radicular symptoms?

A

There is not always a distinct pattern:

  • can be unrelenting
  • may be worse at night
  • may ease up for a few days and then return
  • sometimes respond to opening or closing of the IVF
  • sometimes respond to traction on and off the NR
47
Q

Cervical radicular symptoms may get worse with what movement of the neck?

A
  • compression
  • extension
  • ipsilateral rotation
  • ipsilateral lateral flexion
48
Q

Cervical radicular symptoms may get better with what movement of the neck?

A
  • traction
  • flexion
  • contralateral rotation
  • contralateral lateral flexion
49
Q

What positions may reduce traction on a cervical nerve root?

A
  • Bakody’s
  • shoulder abduction
  • cradling the arm or resting on abdomen
50
Q

What are the three most common causes of radicular syndrome in the cervical spine?

A
  • osteophytes
  • disc herniations
  • spinal stenosis
51
Q

What are the 5 less common (B-list) causes of cervical radiculopathy?

A
  • trauma
  • structural instability
  • tumor/SOL
  • infection
  • NR adhesions
52
Q

What are the 3 unlikely causes (C-list) of cervical radiculopathy?

A
  • disc derangement
  • facet syndrome
  • joint dysfunction

VERY unlikely especially if there are neuro deficits

53
Q

Based on experimental trauma, what percentage of cord volume can be lost and still have normal neurological findings?

A

30%

54
Q

IF a patient is determined to have a NR problem, what is the next step?

A

Make sure the cord is not also involved

The reverse is also true

55
Q

What are the general patterns of myelopathy in the cervical spine?

A
  • Motor and reflex changes more common than sensory
  • analgesia (deficits) are more common than anesthesia (depressed)
  • LMNL at level of compression
  • UMNL below level of lesion
  • arm findings can be unilateral
  • leg findings typically bilateral
56
Q

WHat is more commonly the presenting symptom in cervical myelopathy?

A
  • Motor and reflex changes

- NOT pain

57
Q

What is commonly an early sign observed in patients with cervical myelopathy?

A

Gait disturbances

  • stumbling
  • clumsy
  • Frequent falls
58
Q

What systemic symptoms may be present in 2/3 of cervical myelopathy patient’s?

A

Bladder dysfunction

  • frequency
  • urgency
  • incontinence
  • retention
59
Q

What is L’ermitte’s sign? What is it associated with?

A

An electric shock like sensation running through the back and limbs upon flexion of the neck. Associated with cervical cord lesion because flexion stretches dorsal column

60
Q

What are three diseases that can cause cervical cord lesions?

A
  • compression for SOL, etc.
  • MS
  • B12 deficiency
61
Q

What motor signs will be observed in the hands with cervical cord lesion?

A

Little finger escape sign with fingers squeezed together and into extension

62
Q

If a cervical cord diagnosis is suspected, what ancillary study is indicated?

A

MRI

63
Q

What abnormal reflexes will be present with cervical cord lesion?

A
  • Hyperrefelxia
  • Paradoxical reflexes
  • Clonus
  • Pathological reflex (babinski, hoffman)
  • may be present in all four extremities
64
Q

What is Tromner sign?

A
  • Flick middle finger up

- Positive test is index and thumb approximation

65
Q

What is Hoffman’s reflex?

A
  • flick middle fingertip down

- positive test is index and middle finger approximation

66
Q

What is dynamic Hoffman’s and when would it be used?

A
  • Patient flexes and extends neck while doctor flicks middle finger tip down.
  • This can help tease out Hofmann’s reflex
  • will be positive in extension but normal in flexion
67
Q

What is a positive Babinski?

A

Big toe extends and toes fan

68
Q

When vibration is tested with a tuning fork on the DIP of the middle finger and toe, how many seconds should it be able to be felt?

A
  • 15 seconds or more is considered normal

- under 10 is considered abnormal

69
Q

How is proprioception tested?

A
  • position sense by moving patient’s joints with their eyes closed and seeing if they can indicate the direction
70
Q

What is the most common cause of cord compression in patients under 50?

A

Herniation, midline

71
Q

What is the most common cause of herniation in patients over 60?

A

Stenosis with spondylitic changes

72
Q

About what percentage of patients with disc herniations have myelopathy, according to one study?

A

15%

So important to check all patients with herniations for cord involvement

73
Q

Other than herniation and stenosis, what are the less common causes of cervical cord compression (B-list)?

A 
Trauma
Structural instability
Tumor/SOL
Infection
Fracture
Spinal cord adhesions

Usually not just spurs or osteophytes

LeFebvre (29 decks)

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