Back and Neck Pain Flashcards
L4 Neurologic Level
Tibialis Anterior
Patellar Reflex
Sensation on medial part of leg and big toe
L5 Neurologic Level
Extensor Hallicis Longus
No Reflex
Sensation on middle aspect of leg toes 2-4
S1 Neurologic Level
Fibularis Longus and Brevis
Achilles Reflex
Sensation on lateral aspect of leg and little toe
FABER test
FABER: for Flexion, ABduction, and External Rotation is performed to evaluate pathology of the hip joint or the sacroiliac joint. The test is performed by having the tested leg flexed, abducted, and externally rotated.
Babinski Test
Babinski test is only for pediatric patients, this would be abnormal in adults – elicits flexion of all toes (normal), but positive test is extension of toes
Straight Leg Lift Test vs. Reverse Straight Leg Test
Straight Leg test: lift leg, and abnormal/positive test will cause pain indicative of a sciatic nerve compression
Reverse: Femoral nerve stretch test
Spurling’s Test
Spurling test: compress foramen and reproduce arm pain, which shows signs of radiculopathy in cervical spine
Muscle Testing: C5-T1
C5-deltoid C5-biceps C6-radial wrist extensors C7-triceps C7-flexor carpi radialis (FCR) C8-flexor digitorum sublimus (FDS) to ring finger T1-first dorsal interosseous
Hoffman Reflex
w/ pt’s hand relaxed, flick the long fingernail & look for index finger & thumb flexion
Sign of long-tract spinal cord involvement
Quick Exam
Look at posture/general appearance Crouched/hunched over, neck ROM? Do they appear to be in legitimate pain Palpate neck/back Check motion Flex/ext/sidebend/rotate etc
Check active/passive ROM of all large joints
Check muscle strength
Check reflexes
Check neurovascular status
Provocative tests
Straight leg raise, femoral nerve stretch, Spurling’s etc
Waddall signs- are they really in pain or not?
Cervical Radiculopathy: Relief
Pain relieved by placing hands on head
Opens neural foramen
Cervical Radiculopathy: Tests
Physical exam
Assess alignment
ROM
Motor & sensory exam
R/O shoulder pathology, vascular disturbances & peripheral nerve entrapment
Signs of UMN involvement suggest spinal cord compression
Cervical Spondylosis
Degenerative disk disease (DDD) of the cervical spine
Produced by ingrowth of bony spurs, buckling or protrusion of the ligamentum flavum &/or HNP
Result in narrowing of the neural foramen & stenosis of cervical spinal canal
Can cause neck pain, radiculopathy &/or myelopathy
Cervical Spondylosis: Symptoms
Most common is limited mobility of the cervical spine & chronic neck pain that worsens with upright activity
Radicular symptoms & pain may occur in the UE’s w/ lateral recess stenosis & nerve root entrapment
Many asymptomatic patients will show these changes
Narrowing of the spinal canal & resultant myelopathy are more common in older men
Myelopathy vs. Radiculopathy
Radiculopathy is compression on the nerve root(s)
Myelopathy is compression on the cord Trunk or leg dysfunction Gait disturbances Bowel or bladder changes Signs of UMN involvement more common with stenosis
Cervical Spondylosis: PE
Assess neck ROM
Check motor & sensory distributions of UE/LE
Assess gait & bowel/bladder function
Hoffman reflex, clonus, Babinski
+ in patients with myelopathy
These are your UMN signs
Radiculopathy has same findings as HNP
Abnormal reflexes & motor/sensory dysfunction
Cervical Strain Clinical Symptoms
Cervical pain may follow an incident of trauma or may be spontaneous in onset
Nonradicular, nonfocal neck pain, noted anywhere from the base of the skull to the cervicothoracic junction, is most common
SCM &/or trapezius pain is also common
Pain often worse w/ motion & may be accompanied by paraspinal spasm
Occipital headaches common
Pain following trauma lasts longer
Cervical Strain PE
Areas of tenderness in paraspinous muscles, trapezii, SCM ,spinous processes, interspinous ligaments &/or medial border of scapula
Limited ROM is common
Pain noted in extremes of motion
Neuro exam is normal
Cervical Strain Dx Tests
AP, lateral & open mouth xrays necessary w/ hx of trauma, neuro deficits or elderly
Assess soft tissues
Assess normal lordotic curve
Look for degenerative changes w/ pain, look for instability
Flex/ext films by specialist
Fx of C-Spine
Result from high energy trauma
Beware in unconscious or intoxicated patients- cause of most missed c-spine fxs
Severe neck pain, paraspinous muscle spasm &/or point tenderness
Radicular pain suggests nerve root impingement
Global motor/sensory deficits suggest spinal cord injury
The absence of pain does not “clear” the patient or eliminate the possibility of cervical spine injury
Fx of C-Spine: PE
Inspect for swelling & contusions
Palpate for tenderness & paraspinal spasm
Look for step-offs: suggest PLL injury…instability
Assess motor/sensory function
Perianal sensation, sphincter tone & bulbocavernosus reflex
Fx of C-Spine: Dx Imaging
AP, lateral & open mouth view
Most important is cross-table lateral view
CT- most commonly missed injuries at top & bottom of c-spine
Flex/ext views to assess stability
Fx of C-Spine: Tx
Immobilize immediately via c-collar and backboard: suspect injury until proven otherwise
Stable injuries can be treated with collar/immobilization
Unstable injuries require surgical stabilization
Cauda Equina Syndrome: Symptoms
Onset can be immediate or progress over hours/days
Radicular pain/numbness typically involves both legs
Typically more severe on one side
**Presence of perineal numbness in a saddle distribution is typical = incontinence
Pain diminishes as paralysis progresses
Cauda Equina Syndrome: Dx Tests
MRI or CT myelogram mandatory if CES suspected
Plain films can identify structural causes
CBC, ESR, CRP can be used if infection is suspected
Fx of T and L Spines
Moderate to severe back pain
Pain is exacerbated by motion
N/T, weakness, bowel or bladder dysfunction suggest nerve root injury
Burst fracture where piece comes out and compresses nerve
Posterior longitudinal ligament damage needs to be stabilized, or can cause kyphosis if untreated
Acute LBP
*******Low back strain is an injury to the paravertebral muscles
Because of the deep location of the lumbar soft tissues, however, localizing an injury to a specific structure is difficult, if not impossible
In this area, regardless of which muscle or ligamentous structures have been injured the treatment protocols are identical
A hx of repeated lifting & twisting or operating vibrating equipment may be associated with LBP
***Factors associated with LBP include poor fitness, job dissatisfaction, smoking & various psychosocial issues
Acute LBP: PE
Diffuse tenderness in low back or SI region
ROM (flex) is limited/painful
***LE motor/sensory exam is normal
Chronic LBP
Back pain of more than 3 mo duration
Affects pts from age 30-60
Symptoms recurrent & episodic
*****DDD common diagnosis: normal physiologic process of aging, and does not necessarily imply pain
Chronic LBP: PE
L & SI tenderness is common
**Motor/sensory exam & DTR’s usually normal
Straight-leg raise can be +
**Waddell signs
Lumbar Spinal Stenosis
*******Narrowing of one or more levels of the lumbar spinal canal with subsequent compression of the nerve roots Affects 30% of the population > 60 y/o Not all will have symptoms Degenerative in nature Most common at L3-4, L4-5 & L2-3
Metastatic Disease
Pain is the most common presenting symptom
***Pain is progressive & present at night
Can have compression fxs associated with nerve compression
Progression can be slow or fast depending on the type of tumor
Spondylolisthesis (SPT): Degenerative
***Forward slippage of a lumbar vertebral body that is caused by degeneration & alterations in the facet joints in conjunction with degenerative changes in the disk
Most common in the 4th & 5th vertebral bodies
More common in women > 40 y/o
Retrolisthesis is posterior slippage 2nd to degenerative changes
Spondylolisthesis (SPT): Isthmic
One vertebral body slips in relation to the one below
Usually L5 on S1 in kids
*****A defect at the junction of the lamina & pedicle (pars interarticularis) detaches the ant & mid columns from the posterior column
Most likely due to repetitive loading during adolescence, especially football and gymnastics
Spondylolisthesis (SPT): Isthmic Symptoms and PE
May be symptomatic or asymptomatic
Can have radicular back pain that worsens with standing
*****Tight hamstrings
True nerve compression symptoms rare
**Diminished lumbar lordosis w/ flattening of the buttocks
If significant, can notice a step-off
**Hamstring spasm
Neuro deficits uncommon
