B4-5. Cervical Diseases Flashcards
What are some red flag for disease when a patient presents with neck and/or arm pain?
- 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
What is the triad of Horner’s syndrome?
- ptosis
- meiosis
- anhidrosis
Acute onset of painful Horner’s syndrome with ipsilateral eye, face or neck pain should be treated as what?
should be treated as internal carotid artery dissection until proven otherwise!
What are the most common causes of Horner’s syndrome?
- most are idiopathic
- if they are cause by disease, most common are Tumor, cluster headache, head/nick procedures
What percentage of neck masses in patients > 40 are caused by malignant tumors?
75%
In the absence of overt signs of infection, a lateral neck mass should be considered what?
metastatic squamous cell carcinoma or lymphoma until proven
others.
What are the follow up testing for suspected disease with neck/arm pain?
- radiograph (MRI/CT as needed)
- CRP/ESR
- CBC
- Blood chemistry
What is the typical presentation of a pancoast tumor?
Chronic shoulder pain in a smoker over 50
Describe the pain associated with a pancoast tumor?
- 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
What is a pancoast tumor?
Tumor of the pulmonary apex that can spread to neighboring tissues such as ribs and vertebrae.
What are some neurological signs that may be present with a pancoast tumor?
- 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
What are three possible presentations of cervical instability in a patient with RA?
- 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%)
What is the most common cause of inflammatory arthritis?
RA
What is the estimated prevalence of RA in the general population?
1-2%
Neck pain, suboccipital pain, radiculopathy and myelopathy are common in RA patients. Those without neck pain are typically _______.
Younger (34 years)
Lesser duration of disease (3.5 years)
The degree of cervical involvement in RA patients often correlates with the degree of erosion in what other joints?
Hand a wrist
What are the two blood tests/markers that are usually positive in RA/
- RF
- anti-CCP antibody
Neurological symptoms in RA may include:
- weakness
- gait changes
- paresthesia in hands
- loss of fine dexterity and endurance
- incontinence
- rarely, deficits
How common are neurological symptoms in RA?
Fairly common (5-67%), but neurological deficits are more rare (7-34%)
RA patients, particularly those with Atlanto-axial instability (AAI) can also have what vascular presentation?
Vertebrobasilar artery insufficiency
What are common complaints associated with vertebrobasilar artery insufficiency?
- vertigo
- loss of equilibrium
- visual disturbance
- tinnitus
- dysphagia
NOTE: similar symptomatology can also be caused by mechanical compression of the brainstem
What is Lhermitte sign?
neck motion elicits shock-like sensations through
the torso or into the extremities
What is the most common radiographic finding in RA?
Multiple subluxations
Instability on flexion-extension views of radiograph are indicated by what?
An ADI(atlantodental index) more than 3-4mm in adults and 4mm in children
At what ADI is atlantoaxial instability considered surgical?
More than 8-10mm and before onset of neurological symptoms
What is the Nonoperative treatment of rheumatoid involvement of the cervical spine
- 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
What are the CMT precautions for RA patients?
- 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
Why should chin retraction exercises be avoided in patients with RA?
Retraction causes equal or greater flexion at CO-C1 and C1-C2 than
full-length flexion.
What is the classic presentation of syringomyelia?
- diffuse “cape-like” distribution of pain/temperature loss, especially over one or both shoulders and hands
Other than the classic symptom of syringomyelia, what are some other possible signs and symptoms
- 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
What are the two ways to develop a syrinx?
- chiari 1 malformation is most common
- as a complication from trauma, meningitis, hemorrhage, tumor or arachnoiditis
What is chiari 1 malformation?
Inferior cerebellum protrudes through the foramen magnum into the cervical spinal canal and a syrinx develops in the c-spine cord
At what age does chiari 1 malformation most commonly become symptomatic?
25-40
Symptoms associated with chiari 1 malformation may worsen with what activities?
Straining or any activity that causes CSF pressure to suddenly fluctuate
When do symptoms of syringomyelia appear if it is caused by a complication from trauma, meningitis, hemorrhage, tumor or arachnoiditis?
Months or even years after initial injury
What is the primary symptom of post traumatic syringomyelia?
Pain, which starts at the site of trauma, may be unilateral or bilateral and may spread upward
Other than pain, what are the other neurological symptoms associated with post traumatic syringomyelia?
- numbness
- weakness
- altered temp sense
- ANS symptoms (sweating, loss of sexual, bowel and bladder function)
What is it called when syrinxes affect the brainstem?
Syringobulbia
What kind of diagnostic imaging is indicated for syringomyelia?
MRI, CT, myelography
What is the treatment for syringomyelia?
- 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
What is the typical pain pattern for VBA dissection?
Occiput
What is the typical pain pattern for internal carotid artery dissection?
Lateral neck, temporal head, eye
What is the classic triad of carotid dissection and what percentage of patients have all three?
- unilateral pain in head, neck or face
- partial Horner’s syndrome (ptosis, meiosis)
- cerebral or retinal ischemia
Less than 1/3 have all three
With a carotid artery dissection, which is more common? Headache or neck pain?
Headache occurs in 70% of cases while neck pain occurs in 19% of cases
What is the onset of head, neck and/or face pain associated with carotid artery dissection?
Usually a gradual and continuous onset but it can be sudden and severe
Other than the classic triad of carotid artery dissection, what other symptoms might be seen?
- 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
How is the diagnosis of carotid artery dissection made?
- high index of suspicion and can be confirmed with imaging studies such as convential angiography, duplex scan, MRA or CT angiography
What is a LIKELY risk factor for carotid artery dissection?
Blunt trauma to the neck
What are POSSIBLE risk factors for carotid artery dissection?
- hereditary connective tissue disorders
- hyperhomosysteinemia
- oral contraceptives
- infection (especially chlamydia)
- elevated high-sensitivity C-reactive protein
Cranial nerve palsies were found in 5% of carotid artery dissection patients. What nerves can be affected?
- hypoglossal nerve: tongue weakness
- facial nerve: facial weakness
- oculomotor nerve: diplopia/weak EOM
- trigeminal: facial numbness
What is the typical presentation of VBA dissection that is in progress?
- 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
What are the 9 classic signs of VBA dissection, often referred to as lateral medullary signs/
- ataxia
- dizziness/vertigo
- drop attacks
- diplopia
- dysphagia
- dysarthria
- nausea
- numbness
- nystagmus
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?
Do diagnostic imaging to rule out VBI:
- ultrasound
- MRA
What are some risk factors associated with vertebral artery disease that could lead to dissection?
- Age <45
- history of migraine
- connective tissue disease
- recent infection
What physical exam procedures should be done if VBA is suspected?
- 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
What are 3 emergency referrals/solute contraindications to all treatment modalities?
- 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
Immediate investigation of what 4 signs/symptoms of neurovascular impairment should be done if a patient presents with vertigo?
- unilateral facial paresthesia
- objective cerebellar signs
- lateral medullary signs
- visual field defects
