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MSK 1 > Common Clinical Presentation > Flashcards

Common Clinical Presentation Flashcards

1
Q

List some rare but serious C-Spine health conditions

A
  1. Neoplasm
  2. infection
  3. Ankylosing Spondylitis
  4. RA
  5. Klippel Feil syndrome
  6. CAD
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2
Q

list heightened risk factors for infection

A
  1. immunosuppresion
  2. DM
  3. Cirrhosis
  4. AIDS
  5. steroid use
  6. recent/current infection
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3
Q

What are a few s/s of meningitis?

A

fever, neck stiffness, Kernig’s Sign

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4
Q

What is Kernig’s sign?

A

Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.

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5
Q

define neoplasm

A

a new and abnormal growth of tissue in some part of the body, especially as a characteristic of cancer.

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6
Q

List a few risk factors and s/s of neoplasm

A

prior Hx of cancer

fever and night sweats

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7
Q

what types of cancer are most commonly metasized to the spine?

A

think Lead Kettle (PB KTL)

prostate, breast, kidney, thyoid and lung

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8
Q

T/F: primary cancer is responsible for 75% of bone metastasis

A

TRUE

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9
Q

________ neoplasms metastazie to the vertebrae, pelvis, and proximal femur in 40% of cases

A

Kidney

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10
Q

RA has a greater risk for what?

A
  1. atlantoaxial instability (20-86% of pts with RA)
  2. basilar invagination
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11
Q

what is anklyosing spondylitis?

A

chronic inflammatory spondyloarthropathy

ossification of ligaments of spine, IV discs/end plates, and facet structures

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12
Q

anklyosing spondylitis increases a pt’s risk for what?

A
  1. spinal cord injury (11.4x greater)
  2. epidural hematoma
  3. low-impact trauma (most common in C5-C7)
  4. Osteoporosis (increases to 46-56%)
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13
Q

what population is anklyosing spondylitis more common in?

A

men (10x more likely)

most frequency observed in 3rd decade

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14
Q

a pt with anklyosing spondylitis will most likely have what complaints?

A
  1. back pain (worse at night and in morning, improves w/exercise and worsens w/rest)
  2. decreased chest wall expansion
  3. back stiffness
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15
Q

how will a pt with anylosing spondylitis present physically?

A
  1. visual inspection:
    1. chin on chest position
    2. excessive thoracic kyphosis
    3. flattened L curvature
  2. multi-directional ROM limitations of the spine
  3. diminished mobility of the spine
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16
Q

what would you expect to see on an imaging report for a pt with ankylosing spondylitis?

A

radiographic sacrolitis

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17
Q

what is Klippel Feil syndrome

A

congenital disorder in which there is failed C-spine segmentation

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18
Q

describe the clinical presentation of Klippel Feil syndrome

A
  1. < 50% short neck
  2. low posterior hairline
  3. limited C-spine ROM
  4. >50% have scoliosis
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19
Q

where is fusion most common in Kippel Feil syndrome?

list some complications to this syndrome

A

fusion of C2-3 most common

complication = instability, spinal stenosis

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20
Q

describe the pathophysiology of CAD

A

tear in vessel wall with circulating blood entering tear and forming an intramural hematoma

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21
Q

What are 2 triggering factors for CAD?

A

trauma

infection

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22
Q

List several potential consequences of CAD

A
  1. retinal or brain ischemia
  2. compression or stretching causes local symptoms
  3. subarchnoid or intra-cerebral hemorrhage
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23
Q

CAD accounts for ______ of all ischemic strokes

A

2-3%

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24
Q

There are many risk factors for CAD, list several

A
  1. past history of trauma to C-Spine/cervical vessels
  2. history of migrane-type HA
  3. hypertension
  4. high cholesterol
  5. Cardiac disease
  6. Diabetes
  7. blood clotting disorders and anticoagulant therapy
  8. long-term use of steroids
  9. history of smoking
  10. recent infections
  11. immediatly post partum
  12. trival head or neck trauma
  13. absense of a plausible mechanical explanation for the pt’s symptoms
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25
Q

List symptoms of CAD

A
  1. neck pain (6-80% report)
  2. face pain
  3. HA
    • entire hemicranial or bilateral pain
    • pain in neck, face, head simultaneously
  4. pain is severe (>70%)
  5. (Bilateral) extremity dysesthesia, motor dysfunction, pain
  6. Pulsatile tinnitus
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26
Q

List the 5Ds and 3 Ns of CAD

A
  1. Dizziness
  2. Dysarthria
  3. Dysphagia
  4. Diplopia
  5. Drop attacks
  6. Nystagmus
  7. Nausea
  8. Numbness (dysesthesia of face/lips/extremities)
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27
Q

what findings during a physcial examination could indicate CAD?

A
  1. Horner’s syndrome
  2. HTN
  3. Positional testing
  4. Neurological testing
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28
Q

What is Horner’s Syndrome?

A

Ptosis (dropping of upper eyelid)

Miosis (constriction of pupil) on one side

Enophthalmos (sinking of the orbit)

Anhydrosis (dry eyes)

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29
Q

what is a cervical spine myelopathy?

A

spinal cord compression as a result of impingement from surrounding structures

present in 90% of ppl in 7th decade

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30
Q

what are some common causes of cervical spine myelopathy?

A
  1. ossification of PLL
  2. osteophyte complexes that come up with degenerative changes
  3. bulging discs
  4. soft tissue mass like a cancer
31
Q

list symptoms of cervical spine myelopathy

A
  1. neck pain/stiffness
  2. shoulder pain
  3. imbalance/fal Hx
  4. UE dysesthesia
    • multiple bilateral dematomes invovled usually
    • non-dermatome pattern
  5. May also involve LEs first (gait deviations and weakness)
32
Q

what things on a physical examination might lead you suspect cervical spine myleopathy?

A
  1. Neurologic signs:
    • gait impairments
    • spasticity
    • pathologic reflexes
    • hyper-reflexia
    • dis-coordinated extremity movements
    • radicular signs (usually bilaterally)
    • balance impairments
33
Q

list tests included in the clinical prediction rule for Cervical Spine Myelopathy

A
  1. Gait deviation
  2. Hoffman’s sign
  3. Inverted supinator sign
  4. Babinski Sign
  5. Patient age >45
34
Q

what does the research say about the clincial prediction rules for cervical spine myelopathy? How many tests are needed?

A
  • 1/5 = 94% sensitivity, -LR 0.18
  • 3/5 = 99% specificity, +LR 30.9
  • 4/5 = 100% specificity, +LR infinite

just need 3/5 to be pretty sure

35
Q

what can cause upper cervical instability?

A
  1. ligamentous instability
  2. fracture (either by a trauma or fatigue fracture)
36
Q

what things are associated with an increased risk for upper cervical instability (ligamentous)?

A
  1. history of trauma (whiplash, contact sport, etc.)
  2. throat infection
  3. congenital collagenous compromise
    • Down’s Syndrome, Ehler’s Danlos
  4. inflammatory arthrides
    • RA, anklyosing spondylitis
  5. recent neck/head/dental surgery
37
Q

List symptoms of ligamentous upper cervical instability

A
  1. neck pain
  2. occipital HA/numbness
  3. limitation with activities performed at end-range C-Spine ROM
  4. radicular symptoms
  5. pt communicates the following:
    • must support head w/hands
    • tires easily in prolonged static upright positioning of head
38
Q

what findings during a physical exam might suggest ligamentous upper cervical instability?

A
  1. multi-directional ROM limitations at C/S
  2. muscle guarding
  3. potential radicular signs
39
Q

List several special tests that can be conducted for ligamentous upper cervical instability

A
  1. Modified/Sharp Purser
  2. Alar ligament Stability Test
  3. Tectorial Membrane Test
  4. Posterior A-O Membrane Test
40
Q

upper cervical instability due to fractures is most commonly involving what structures?

A
  1. occipital condyles
  2. C1
  3. C2
41
Q

what is a common mechanism of injury resulting in a cervical fracture and upper cervical instability?

A

axial loading

42
Q

describe the clincial presentation of someone with upper cervical instability related to a fracture

A
  1. multidirection ROM limitations
  2. neck pain
  3. C-Spine spasm
  4. difficulty swallowing
  5. radicular pain
  6. CAD s/s
  7. Myelopathy s/s
43
Q

what is a Jefferson fracture?

A

a specific type of fracture to the atlas

4-part burst fracture of atlas

*most common type of injury is a compression type injury

44
Q

what is the difference between a spondylosis and a spondylolisthesis?

A

spondylosis → defect of pars interarticularis

spondylolisthesis → anterior displacement of vertebral body

a spondylosis often results from a fracture and is unilateral, but if it occur bilaterally it can progress into a sponydlolisthesis

45
Q

how are spondylolisthesi graded?

A

by the % of vertebral body slip:

  1. 0-25%
  2. 25-50%
  3. 50-75%
  4. >75%
46
Q

what are the Canadian C-Spine rules?

A

a clinical rule used to determine if a pt needs radiographic imaging done for the neck

has a really good -LR, very supported by research

47
Q

what is the NEXUS low risk rule?

A

5 criteria in order to be classified as having a low probability of injury.

sensitivity ranges 0.83-1.00 (it’s good)

more suited for a traumatic setting

48
Q

what are the 5 criteria in the Neux low risk rule?

A
  1. no midline cervical tenderness
  2. no focal neurologic deficit
  3. normal alertness
  4. no intoxication
  5. no painful, distracting injury
49
Q

what is the most part of the screening process for upper cervical instability?

A

patient history

50
Q

describe referral patterns for cervical spine arthropathies

A

can show up as a HA or in the anterior chest

51
Q

List 2 types of degenerative arthropathies at the C-spine

A
  1. spondylosis → osteophyte complexes form around the margin of vertebral bodies and disc
  2. Osteoarthrosis → impacts the zygophysial joints and AA joints, osteophytes form narrowing the joint
52
Q

what are some potential causes for central canal stenosis at the C-Spine

A
  1. Z joint hypertrophy
  2. bulging disc
  3. thickening/ossification of ligamentous structures
  4. spondylolysthesis

*central canal stenosis can cause cervical spine myelopathy but they are 2 distinct pathologies

53
Q

what are some potential causes for lateral canal stenosis at the C-Spine?

A
  1. loss of disc height w/degenerative processes
  2. Z-joint and Uncovertebral joint hypertrophy
  3. Spondylolysthesis
54
Q

what is a common cause of actue zygopophysial joint arthropathy?

A

commonly associated with extension mechanism

the lambda shaped meniscoids tend to get inflammed and injured

55
Q

what findings during a physical exam might suggest acute zygopophysial joint arthropathy?

A
  1. pain w/joint compression ROM
  2. painful with segmental provocation
    • CPAs and UPAs
  3. Cervical compression and Spurlings test likely provoke concordant pain, BUT
    • pain observed in segmental distribution
    • pain observed, NOT paresthesia/anesthesia
56
Q

what is the difference between somatic referred pain, radicular pain, and radiculopathy?

A
  1. somatic referred pain → altered pain perception in CNS
  2. radicular pain → pain related to nerve root irritation
  3. radiculopathy → conduction block of motor and sensory axons
57
Q

T/F: radicular pain only ever shows up with radiculopathies

A

FALSE
may occur with or w/o radiculopathy

58
Q

describe the symptoms of radicular pain

A
  1. shooting/lancing pain traveling along nerve root distribution
  2. “band-like”
  3. pain w/activities that close the neuroforamen
    • SB, rotation closing foramen
59
Q

what findings during a physical exam suggest radicular pain?

A
  1. visual inspection → shifting position to open neuroforamen
  2. painful/limited ROM with motions/positions that compress foramen or place tensile load on nerve root
  3. relief with opening neuroforamen
60
Q

what are common causes of radiculopathy?

A

compression or ischemia by:

  1. foraminal stenosis
  2. epidural disorder
  3. meningeal disorder
  4. neurologic disorder
  5. impingement by disc herniation
61
Q

what region of the C-spine is most commonly effected by radiculopathies?

A

C6 and C7

spondylosis with foraminal encroachment in 70% of cases

62
Q

what findings during a physcial exam might suggest a radiculopathy?

A
  1. natural Bakody’s sign
  2. painful/limited ROM w/motions that compress the foramen or place a tensile load on nerve root
  3. relief with neuroforamen opening
  4. Valsalva’s test +
  5. Wainner’s Cluster
63
Q

what is a natural Bakody’s sign?

A

patient is resting hand on top of head

64
Q

what is included in Wainner’s Cluster?

A
  1. Ipsilateral C/S rotation AROM < 60
  2. Spurling’s Test +
  3. Cervical Distraction test +
  4. ULTT +
65
Q

what does research say about Wainner’s Cluster?

A

4/4 is good, less than that not so much

66
Q

describe the pathomechanics of WAD

A
  • trunk thrust forward
  • lower C/S segment rotation into extension
  • anterior annulus distracted, impaction on facet joints
    • anterior annulus, ALL, and facet capsule strain
    • Meniscoid contusion
    • intra-articular hemorrhage of facets
    • fractures of articular pillars/subchondral plates, dens, laminae C2, occipital condyles
67
Q

list symptoms of WAD

A
  1. neck, shoulder, UE pain
  2. radicular vs referred symptoms
  3. glove-like distribution paresthesia
  4. weakness
  5. dizziness
  6. difficulty focusing vision
  7. tinnitus
68
Q

what findings during a physical exam might suggest WAD?

A
  1. radicular signs
  2. C-spine motion limited
  3. weakness
  4. muscle guarding
  5. tinnitis
  6. must be tied to a traumatic event like MVA
69
Q

what is a cervicogenic HA?

A

a HA referred from c/s

70
Q

list the clinical criteria for the diagnosis of cervicogenic HA

A
  1. unilateral HA w/o side shift
  2. s/s of neck involvement
  3. pain episodes of varying duration or fluctuating continuous pain
  4. moderate, non-excurciating pain, usually a non-throbbing nature
  5. pain starting at the neck, spreading to oculo-frontal-temporal areas
  6. anaesthetic blockade abolishment of pain
  7. various attack-related events
71
Q

what are s/s of neck involvement in a cervicogenic HA?

A
  1. pain triggered by neck movement or sustained awkward posture
  2. ipsilateral neck, shoulder, and arm pain
  3. reduced ROM
72
Q

what are attack-related events?

A
  1. autonomic s/s
  2. N/V
  3. ipsilateral oedema and flushing in peri-ocular area
  4. dizziness
  5. photophobia
  6. phonophobia
  7. blurred vision in the ipsilateral eye
73
Q
A

MSK 1 (17 decks)

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