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Spinal Disorders- LeFebvre > B4-5. Cervical Diseases > Flashcards

B4-5. Cervical Diseases Flashcards

1
Q

What are some red flag for disease when a patient presents with neck and/or arm pain?

A
  • prior CA history
  • unexplained weight loss
  • unvarying symptoms
  • sharp, sever, intolerable pain
  • fever/chills
  • recent bacterial infection
  • pain unimproved with months of treatment
  • multiple joints involved
  • smoker over the age of 50
  • recent infection + fever + neck stiffness
  • nuchal rigidity
  • palpable mass
  • horner’s syndrome
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2
Q

What is the triad of Horner’s syndrome?

A
  • ptosis
  • meiosis
  • anhidrosis
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3
Q

Acute onset of painful Horner’s syndrome with ipsilateral eye, face or neck pain should be treated as what?

A

should be treated as internal carotid artery dissection until proven otherwise!

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4
Q

What are the most common causes of Horner’s syndrome?

A
  • most are idiopathic

- if they are cause by disease, most common are Tumor, cluster headache, head/nick procedures

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5
Q

What percentage of neck masses in patients > 40 are caused by malignant tumors?

A

75%

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6
Q

In the absence of overt signs of infection, a lateral neck mass should be considered what?

A

metastatic squamous cell carcinoma or lymphoma until proven

others.

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7
Q

What are the follow up testing for suspected disease with neck/arm pain?

A
  • radiograph (MRI/CT as needed)
  • CRP/ESR
  • CBC
  • Blood chemistry
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8
Q

What is the typical presentation of a pancoast tumor?

A

Chronic shoulder pain in a smoker over 50

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9
Q

Describe the pain associated with a pancoast tumor?

A
  • initially occurs in shoulder, medial border of scapula
  • may later radiate along ulnar nerve (C8)
  • often relentless and unremitting
  • supporting elbow can ease tension on shoulder and upper arm
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10
Q

What is a pancoast tumor?

A

Tumor of the pulmonary apex that can spread to neighboring tissues such as ribs and vertebrae.

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11
Q

What are some neurological signs that may be present with a pancoast tumor?

A
  • ipsilateral Horner’s syndrome
  • weak and strophic hand muscles
  • absent triceps reflex
  • if spinal cord or NR is invaded, will have symptoms of myelopathy/radiculopathy
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12
Q

What are three possible presentations of cervical instability in a patient with RA?

A
  • C1-C2 instability causing subluxation (usually anterior, 50% of RA patients)
  • proximal migration of the odontoid (40% of RA patients)
  • subaxial instability (very common but rarely occurs alone, only 10-20%)
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13
Q

What is the most common cause of inflammatory arthritis?

A

RA

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14
Q

What is the estimated prevalence of RA in the general population?

A

1-2%

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15
Q

Neck pain, suboccipital pain, radiculopathy and myelopathy are common in RA patients. Those without neck pain are typically _______.

A

Younger (34 years)

Lesser duration of disease (3.5 years)

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16
Q

The degree of cervical involvement in RA patients often correlates with the degree of erosion in what other joints?

A

Hand a wrist

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17
Q

What are the two blood tests/markers that are usually positive in RA/

A
  • RF

- anti-CCP antibody

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18
Q

Neurological symptoms in RA may include:

A
  • weakness
  • gait changes
  • paresthesia in hands
  • loss of fine dexterity and endurance
  • incontinence
  • rarely, deficits
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19
Q

How common are neurological symptoms in RA?

A

Fairly common (5-67%), but neurological deficits are more rare (7-34%)

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20
Q

RA patients, particularly those with Atlanto-axial instability (AAI) can also have what vascular presentation?

A

Vertebrobasilar artery insufficiency

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21
Q

What are common complaints associated with vertebrobasilar artery insufficiency?

A
  • vertigo
  • loss of equilibrium
  • visual disturbance
  • tinnitus
  • dysphagia

NOTE: similar symptomatology can also be caused by mechanical compression of the brainstem

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22
Q

What is Lhermitte sign?

A

neck motion elicits shock-like sensations through

the torso or into the extremities

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23
Q

What is the most common radiographic finding in RA?

A

Multiple subluxations

24
Q

Instability on flexion-extension views of radiograph are indicated by what?

A

An ADI(atlantodental index) more than 3-4mm in adults and 4mm in children

25
Q

At what ADI is atlantoaxial instability considered surgical?

A

More than 8-10mm and before onset of neurological symptoms

26
Q

What is the Nonoperative treatment of rheumatoid involvement of the cervical spine

A
  • Mainly supportive (bracing, cervical stabilizing exercises, radiographic monitoring for impending neurological compromise)
  • Aggressive medical management is also important, because cervical involvement has been correlated with disease activity
27
Q

What are the CMT precautions for RA patients?

A
  • Because they are at a high risk fo cervical instability, prior to manipulation flexion-extension radiographs should be obtained even if the patient is not symptomatic.
  • low force techniques should be used
  • cervical traction is contraindicated
  • avoid chin retraction exercises
28
Q

Why should chin retraction exercises be avoided in patients with RA?

A

Retraction causes equal or greater flexion at CO-C1 and C1-C2 than
full-length flexion.

29
Q

What is the classic presentation of syringomyelia?

A
  • diffuse “cape-like” distribution of pain/temperature loss, especially over one or both shoulders and hands
30
Q

Other than the classic symptom of syringomyelia, what are some other possible signs and symptoms

A
  • chronic, severe pain
  • slow progressive weakness in arms and legs
  • stiffness in back shoulders, arms and/or legs
  • headache
  • loss of bladder function
  • UMNL findings in UE
  • LMNL findings in LE

Different combination of symptoms depend on the location of the syrinx in the spinal cord

31
Q

What are the two ways to develop a syrinx?

A
  • chiari 1 malformation is most common

- as a complication from trauma, meningitis, hemorrhage, tumor or arachnoiditis

32
Q

What is chiari 1 malformation?

A

Inferior cerebellum protrudes through the foramen magnum into the cervical spinal canal and a syrinx develops in the c-spine cord

33
Q

At what age does chiari 1 malformation most commonly become symptomatic?

A

25-40

34
Q

Symptoms associated with chiari 1 malformation may worsen with what activities?

A

Straining or any activity that causes CSF pressure to suddenly fluctuate

35
Q

When do symptoms of syringomyelia appear if it is caused by a complication from trauma, meningitis, hemorrhage, tumor or arachnoiditis?

A

Months or even years after initial injury

36
Q

What is the primary symptom of post traumatic syringomyelia?

A

Pain, which starts at the site of trauma, may be unilateral or bilateral and may spread upward

37
Q

Other than pain, what are the other neurological symptoms associated with post traumatic syringomyelia?

A
  • numbness
  • weakness
  • altered temp sense
  • ANS symptoms (sweating, loss of sexual, bowel and bladder function)
38
Q

What is it called when syrinxes affect the brainstem?

A

Syringobulbia

39
Q

What kind of diagnostic imaging is indicated for syringomyelia?

A

MRI, CT, myelography

40
Q

What is the treatment for syringomyelia?

A
  • refer for pain medication and surgical consult in order to stop progression by draining the syrinx and creating more space in the foramen magnum
  • Delay in treatment may result in irreversible spinal cord injury
  • syringomyelia may recur
41
Q

What is the typical pain pattern for VBA dissection?

A

Occiput

42
Q

What is the typical pain pattern for internal carotid artery dissection?

A

Lateral neck, temporal head, eye

43
Q

What is the classic triad of carotid dissection and what percentage of patients have all three?

A
  • unilateral pain in head, neck or face
  • partial Horner’s syndrome (ptosis, meiosis)
  • cerebral or retinal ischemia

Less than 1/3 have all three

44
Q

With a carotid artery dissection, which is more common? Headache or neck pain?

A

Headache occurs in 70% of cases while neck pain occurs in 19% of cases

45
Q

What is the onset of head, neck and/or face pain associated with carotid artery dissection?

A

Usually a gradual and continuous onset but it can be sudden and severe

46
Q

Other than the classic triad of carotid artery dissection, what other symptoms might be seen?

A
  • TIA, stroke symptoms (50-90%)
  • transient monocular blindness (6-30%)
  • visual scintillations (33%)
  • subjective bruit (25-48%)
  • impaired taste (10-19%)
  • aphasia
  • pulsation tinnitus
  • ataxia
47
Q

How is the diagnosis of carotid artery dissection made?

A
  • high index of suspicion and can be confirmed with imaging studies such as convential angiography, duplex scan, MRA or CT angiography
48
Q

What is a LIKELY risk factor for carotid artery dissection?

A

Blunt trauma to the neck

49
Q

What are POSSIBLE risk factors for carotid artery dissection?

A
  • hereditary connective tissue disorders
  • hyperhomosysteinemia
  • oral contraceptives
  • infection (especially chlamydia)
  • elevated high-sensitivity C-reactive protein
50
Q

Cranial nerve palsies were found in 5% of carotid artery dissection patients. What nerves can be affected?

A
  • hypoglossal nerve: tongue weakness
  • facial nerve: facial weakness
  • oculomotor nerve: diplopia/weak EOM
  • trigeminal: facial numbness
51
Q

What is the typical presentation of VBA dissection that is in progress?

A
  • Sudden, severe pain in the side of the head or neck (unlike any pain the patient has experienced before) up to 2 weeks before other symptoms
  • 2/3 of patients have headaches 15 hours before other symptoms

NOTE: pain in posterior neck is more frequent in VBA dissection that carotid artery dissection

52
Q

What are the 9 classic signs of VBA dissection, often referred to as lateral medullary signs/

A
  • ataxia
  • dizziness/vertigo
  • drop attacks
  • diplopia
  • dysphagia
  • dysarthria
  • nausea
  • numbness
  • nystagmus
53
Q

Should you manipulate a patient with new headache and neck pain affecting the upper quadrant of the neck along with occipital or hemicranial pain, especially if associated with vertigo?

A

Do diagnostic imaging to rule out VBI:

  • ultrasound
  • MRA
54
Q

What are some risk factors associated with vertebral artery disease that could lead to dissection?

A
  • Age <45
  • history of migraine
  • connective tissue disease
  • recent infection
55
Q

What physical exam procedures should be done if VBA is suspected?

A
  • blood pressure (HTN)
  • pulse (tachycardia due to infection)
  • observation and peripheral joint hyperflexibility and skin elasticity (connective tissue disease)
  • auscultation (mitral valve disorder)
  • abdominal palpation (polycystic disease)
  • assessment of cranial and peripheral nerve function
56
Q

What are 3 emergency referrals/solute contraindications to all treatment modalities?

A
  • Sharp neck/occipital pain with sudden severe onset unlike anything
    previous!
  • Severe, persistent HA unlike anything previous!
  • 1 of 4 of the following signs: unilateral facial paresthesia, objective
    cerebellar signs, lateral medullary signs, visual field defects
57
Q

Immediate investigation of what 4 signs/symptoms of neurovascular impairment should be done if a patient presents with vertigo?

A
  • unilateral facial paresthesia
  • objective cerebellar signs
  • lateral medullary signs
  • visual field defects

Spinal Disorders- LeFebvre (25 decks)

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