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OMM T2 Exam2 > Differential Diagnosis of Neck Pain > Flashcards

Differential Diagnosis of Neck Pain Flashcards

1
Q

What are some etiologies of neck pain?

A

Congenital Disorders Trauma Mechanical Abnormalities Toxicity Metabolic Disorders Inflammatory States Degenerative & Acquired Spinal Diseases Infections

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2
Q

What are some more etiologies of neck pain?

A

Temporomandibular Joint Dysfunction Thoracic Outlet Syndrome Neoplasms Circulatory Disorders Neurologic Disorders Referred Pain Iatrogenic Psychoneuroses

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3
Q

What is the “job one” in neck pain diagnosis?

A

Rule Out Any Life, Limb, Organ , and Function Threatening Conditions

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4
Q

During diagnosis, what demographics make you worry?

A

Age Less Than 20 years Age Over 50 years

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5
Q

During diagnosis, what vital signs make you worry?

A

Fever Hypertension

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6
Q

During diagnosis, what type of medical history makes you worry?

A

Trauma Fever Abrupt Onset Neurologic Symptoms (Radicular Pain, Muscle Weakness, Muscle Cramps, Decreased Sensation)

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7
Q

During diagnosis, what findings in the pt’s physical make you worry?

A

RROM severely restricted (<1/2 the normal range), Radicular symptoms provoked by ROM, Signs of Inflammation, Neurologic Deficits

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8
Q

Major Category: Congenital Disorders

A

Condition Present Since Childhood, Onset of Symptoms often Insidious, and Symptoms may appear At Any Age, but usually in the late teens to mid-thirties

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9
Q

Major Category: Trauma

A

Any history of trauma

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10
Q

Major Category: Mechanical

A

Insidious Onset

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11
Q

Major Category: Toxins

A

Exposure to toxins: Vocational, Avocational, Incidental

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12
Q

Major Category: Metabolic Disorders

A

Endocrine: DM, Thyroid disease. Nutrition: Ingestion, digestion, excretion

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13
Q

Major Category: Inflammatory

A

Abrupt onset: Redness, tumor, fever and pain.

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14
Q

Major Category: Degenerative

A

Age 50 and older, need imaging

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15
Q

Major Category: Infectious

A

Fever, WBC elevated, need imaging

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16
Q

Major Category: Neoplasm

A

Age 50 and older, need imaging

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17
Q

Major Category: Circulatory

A

-Vital Signs: Pulse rate, Blood Pressure. -Physical Exam: Palpate Pulses, Auscultate Heart, Auscultate Arteries

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18
Q

Major Category: Neurologic

A

Muscle Weakness or Spasm, Reflex Alterations, Sensory Loss, Pain which follows the distribution of: Nerve Root, Peripheral Nerve

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19
Q

Major Category: Iatrogenic

A

History of Presence of Iatrogen (caused by another physician)

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20
Q

Major Category: Psychogenic

A

Diagnosis of exclusion

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21
Q

Patients with possible trauma and/or fall…

A

Yield possibility of fracture

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22
Q

When you suspect fracture, what are the possible observations in the pt’s PE?

A

Unusual head carriage, careful palpation of cervical SP, percussion of SP of C2 &C7, severely restricted active ROM.

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23
Q

When you suspect fracture, what is a must do ?

A

X-ray of the pt’s complete cervical spine

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24
Q

When you suspect fracture, what should you avoid ?

A

Passive motion testing

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25
Q

When does percussive pain present?

A

Fracture, Tumor, Osteomyelitis, Infectious Discitis, Facet Joint Synovitis

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26
Q

What are some red flags in a pt with facet dislocation?

A

Violent rotational injury, Can occur with sudden voluntary head turning, Patient may hear a “Click” as the facets lock, Pain is present at the site of injury

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27
Q

What are some physical findings in a pt’s with facet dislocation?

A

Abnormal head carriage-torticollis, Palpate Articular pillars for facet dislocation, Neurologic Exam, X-ray Confirmatory

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28
Q

Unilateral facet joint dislocation causes…

A

No neurologic compromise

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29
Q

Bilateral facet joint dislocation causes…

A

Compression of Spinal Cord

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30
Q

What symptoms will a pt with a herniated cervical disc present?

A

Neck pain which radiates into the shoulder, arm, forearm, wrist or hand

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31
Q

Describe the history of a pt with a herniated cervical disc due to trauma?

A

Presence of Pain which radiates into a dermatomal distribution. Numbness or Paresthesias in a Dermatomal Distribution

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32
Q

Describe the PE of a pt with a herniated cervical disc due to trauma?

A

Observe – May be abnormal head carriage and Loss or reversal of Cervical Lordosis. Palpate – Tenderness and muscle spasm at the level of the herniated disc

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33
Q

Describe the PE of a pt with a herniated cervical disc due to trauma? #2

A

Active ROM restricted in Flexion, may be restricted in other directions as well. Valsalva Test reproduces radicular pain.

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34
Q

Describe the PE of a pt with a herniated cervical disc due to trauma? #3

A

Flexion/Compression Test reproduces pain in nerve root distribution. Lhermitte Sign may be present

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35
Q

Valsalva Test

A

Reproduces the symptoms of any space occupying lesion within the spinal canal

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36
Q

Cervical Compression Test

A

Exert a downward (vertically) force in pt’s head. (perform only if valsalva is negative)

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37
Q

Distraction Test

A

With one hand in the pt’s occiputand the other under the pt’s chin, exert an upward force.

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38
Q

Lhermitte Sign

A

Electrical Shock Paresthesia down back, arms, legs with flexion of the neck. Occurs with any cause of spinal cord compression and with many causes of spinal cord inflammation

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39
Q

What other tests do you perform in a pt with a herniated cervical disc?

A

Sensory test for touch and pain. Muscle strength testingWa

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40
Q

Muscle strength testing for Herniated disc includes which muscles and vertebrae?

A

C5 – Deltoid C5 – Serratus Anterior C5/C6 – Biceps C6 – Wrist Extensors

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41
Q

Muscle strength testing for Herniated disc includes which muscles and vertebrae? #2

A

C7 – Triceps C7 – Wrist Flexors C7 – Finger Extensors C8 – Finger Flexors T1 - Interossei

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42
Q

Which reflexes are tested during the PE of a pt with herniated cervical disc?

A

C5 – Biceps Reflex C6 – Brachioradialis C7 – Triceps Reflex

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43
Q

If a pt with a herniated disc has a nerve root compression, what symptoms will he/she present?

A

Sensory Loss Muscle Weakness Reflex Loss

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44
Q

Spinal cord compression in a pt with herniated disc will cause…

A

Sensory Deficits, Muscle Spasticity, Hyperreflexia, Clonus, Abnormal Reflexes: Hoffman & Babinski

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45
Q

Describe the hoffman test

A

Squeeze the tip of pt’s middle finger

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46
Q

What would imaging show in a pt with a herniated disc?

A

straightening or reversal of cervical lordosis. MRI confirms neurologic findings

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47
Q

What are some findings seen during a PE of a pt with cervical s&s?

A

Flattening of Cervical Lordosis. Abnormal Head Carriage – Torticollis. Normal neurologic exam.

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48
Q

What muscles (or structures) may get tender and spastic in pts’ with cervical s&s?

A

SCM, scalene, paravertebral, superior trapezius border, levator scapula scapular attachment, nuchal ligament.

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49
Q

SCM tearing and hematoma formation may be caused by…

A

Hyperextension injury of neck (classic injury of whiplash)

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50
Q

When were head restraints first implemented in cars?

A

Late 1960s

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51
Q

What are some findings seen during a PE of a pt with cervical s&s? #2

A

Restricted and/or Asymmetric Active ROM, Neurologic Examination will be normal, Distraction Test may be painful

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52
Q

Distraction test in a pt with cervical s&s will cause…

A

Dolor

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53
Q

X ray of a pt with cervical s&s will show…

A

absence of fracture, loss of normal cervical lordotic curve

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54
Q

Which muscles are responsible for cervical s&s?

A

Scalenes Paravertebral

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55
Q

What can cause Torticollis?

A

Strain Sternocleidomastoid Muscle
Strain Scalene Musculature
Muscular Ischemia
Facet Dislocation with Overriding (C2 to C7)
C1-C2 Dislocation

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56
Q

Congenital Torticollis

A

The condition has been present since birth

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57
Q

How would you asses a newborn for congenital torticollis?

A

By testing cervical range of motion in sidebending and rotation
Normal – 30 degrees sidebending, 90 degrees rotation

58
Q

What percentage of healthy new borns have Torticollis?

A

16%

59
Q

What are the risk factors for Congenital torticollis?

A

Mother feeling the fetus “stuck” in one position for six weeks or more.
Presence of other Birth Trauma
–Cephalohematoma
–Clavicular Fracture
–Brachial Plexus Injury
Prolonged Second Stage of Labor

60
Q

List the congenital etiologies of Torticollis

A

Klippel-Feil Syndrome
Basilar Impression
Atlanto-occipital Fusion
Pterygium Colli (web neck)
Odontoid Abnormalities

61
Q

Klippel-Feil Syndrome

A

Cervical Spine congenital anomaly consisting of multiple fused vertebrae, possibly Hemivertebrae and other anomalies

62
Q

Hypoplastic dens may be present in

A

Achondroplastic Dwarfism
Down Syndrome

63
Q

Patients with Klippel-Feil Syndrome will present with…

A

Localized neck pain.
Significantly reduced cervical range of motion.
Segmental motion testing demonstrates total motion loss, not just restriction

64
Q

Inflammatory Etiologies of Torticollis

A

Lymphadenitis in the Neck-causes SCM spasm
Tuberculosis
(Vertebral Destruction,Muscle Spasm)
Typhoid
(Muscle Spasm)
Rheumatoid Arthritis
(Spontaneous Atlanto-axial rotatory subluxation)

65
Q

How does Rheumatoid Arthritis causes Torticollis?

A

It erodes away the Transverse Odontoid Ligament with subluxation of the dens posteriorly into the spinal canal

66
Q

If patient has evidence of RA elsewhere in the body…

A

Perform flexion/extension films of the odontoid before considering a manipulative approach

67
Q

List the neurologic etiologies of torticollis

A

Ocular Dysfunction
Syringomyelia
Spinal Cord Tumor
Cerebellar Tumor

Bulbar Palsies
Spasmodic Torticollis

68
Q

Facts about Syringomyelia

A

Central Cavitation of the Spinal Cord
M:F – 7:3
Symptoms appear during the 2nd & 3rd Decade of Life
Usually lower cervical to upper thoracic covering 6-7 spinal segments

69
Q

What are some symptoms of Syringomyelia? #1

A

Restricted RROM
Awkwardness and Weakness of the Hands & Fingers.
Muscle Atrophy and Contracture, development of a “Claw Hand”
Radicular pain is unusual and if present mild

70
Q

What are some symptoms of Syringomyelia? #2

A

Impaired pain and temperature sensation
Preservation of muscle sense and light touch
Vibration and Position sense are often defective
Hyperactive Deep Tendon Reflexes

Loss of Balance is a Possibility

71
Q

Signs of Syringomyelia

A

Neck pain, kyphosis, scoliosis

72
Q

Torticollis can also be seen in…

A

Acute Idiophatic Cervical Disc Calcification

Sandifer’s Syndrome (hiatus hernia, gastroesophageal reflux)

73
Q

RED FLAGS for possible infection

A

Age Over 50 Years
Age Under 20 Years
Fever or Chills
Pain worse supine

Recent Urinary Tract Infection
IV Drug Abuse
Immune Suppression

74
Q

What are some red flags you can find during a physical examination?

A

–Fever
–Spinous Process Percussive Pain
C2, C7 & T1 Only ones that can be percussed

75
Q

What are some red flags you can find in labs?

A

–Elevated wbc count
–Elevated Erythrocyte Sedimentation Rate

76
Q

What are some possible infections related to neck pain?

A

Sinusitis
Cervical Adenitis
Parotitis
Lyme Arthritis
Osteomyelitis

77
Q

List the red flags for a possible tumor

A

–Age over 50 years
–Age under 20 years
–Unexplained Weight Loss
–Pain worse when Supine
–Severe Nocturnal Pain

78
Q

Anyone with a history of cancer…

A

has METASTATIC CANCER until you can prove they don’t

79
Q

List some tumors you can find in the neck

A

Parotid Tumor

Lymphoma

Lymphangioma

Neuroma

Meningioma

Metastatic Lung Cancer

80
Q

When suspecting a circulatory disorder, what should be checked during the PE?

A

BP, Pulse Rate, Palpate Carotid Pulses(presence, character, thrill),

Auscultate: Heart (murmurs),

Carotid Arteries (bruits),

Vertebral Arteries – at mastoid processes (bruits), Ophthalmic Arteries – over the eyeballs (bruits)

81
Q

Red flags for vertebrobasilar artery compromise

A

Have the sitting patient look up toward the ceiling then turn the head to right. Hold for three seconds, then return to neutral. Repeat for the Left Side

Observe for the development of nystagmus.

82
Q

Is the DeKleyn test recommended when there is a suspicion of vertebrobasilar artery compromise?

A

NO

83
Q

Suspect Cerebral Ischemia when…

A

Patient shows signs of anxiety or panic druing examination or treatment

84
Q

What causes Wallenberg Syndrome?

A

vertebrobasilar thrombosis

85
Q

Symptoms of Wallenberg Syndrome

A

–Homolateral facial pain
–Homolateral facial paresthesia
–Contralateral loss of sensation for pain and temperature on limbs & trunk

86
Q

More symptoms of Wallenberg Syndrome

A

–Intense Vertigo with Vomiting
–Unilateral Paralysis of the Palate, Pharynx & Vocal Cords with “brassy” dysarthria

Dysphagia

Ataxia

Unilateral Horner Syndrome

87
Q

Ischemia can be provoked by…

A

rotation of the neck combined with hyperextension

88
Q

Are mechanical abnormalities typically insidious?

A

YES

89
Q

What are some mechanical abnormalites?

A

Somatic Dysfunction
Kyphosis with Anterior Head Carriage
Scoliosis
Poor Posture
Poor Muscle Tone
Scapulo-Costal Syndrome
Hypermobility

90
Q

What is important in a patient with somatic dysfunction before OMT?

A

Discover any contraindications

91
Q

Somatic dysfunction acompanies and magnifies…

A

neck pain

92
Q

What did a study say about OMT in patients with somatic dysfunction ?

A

Immediate pain relief was seen in both group- patients receiving OMT and patients on Ketorolac Tromethamine IM. However OMT patients showed greater decrease in pain. At 1 hr after treatment there was no significant difference in the 2 groups.

93
Q

What is the characteristic posture of scapulo-costal syndrome?

A

Increased kyphosis with anterior head carriage is typically present in many patients with muscular neck, shoulder & upper back pain

94
Q

Scapulo-Costal Syndrome

A

30% of all neck & shoulder complaints in midlife

Also called –
–Fatigue Postural Paradox Syndrome
–Levator Scapulae Syndrome

95
Q

Where is the scapulo-costal syndrome pain localized?

A

In the superior medial corner of the scapula

96
Q

Characterize Scapulo-costal syndrome

(AKA computer invoked myofascial shoulder pain)

A

Tenderness at the insertion of the levator scapulae muscle
Pain is exacerbated by elevation and adduction of the Humerus
Inflammation followed by fascial scarring in the scapulo-costal fascia will cause crepitance or gross crunching with scapular circumduction

97
Q

What is the treatment for Scapulo-costal syndrome? #1

A

Correct Kyphosis
Correct Scoliosis
Correct Associated Cervical, Thoracic, Costal and Clavicular Somatic Dysfunctions

98
Q

What is the treatment for Scapulo-costal syndrome? #2

A

Balance Shoulder muscle tension
Trigger Point Treatment
–Counterstrain
–Muscle Energy
–Deep Inhibitory Pressure
–Spray & Stretch
–Injection of Lidocaine/Corticosteroids

99
Q

Describe Intern’s neck

A

Neck and Shoulder Pain
Caused by Excessive Pull on the Suspensory Muscles of the Shoulders

100
Q

Etiology of Intern’s neck

A

Overloading the Pockets of the Great White Coat

Transfer Weight Off the Shoulders and onto the Pelvis Which is Better Designed to Handle the Load – Wear a carpenter’s Utility Belt

101
Q

Some facts about hypermobility syndrome

A

Can occur in any joint including the spine
Can be localized due to ligamentous trauma, or local degenerative disc disease
Can be generalized due to genetic collagen defects resulting in laxity of ligaments

102
Q

How to treat Localized Hypermobility syndrome #1

A

OMT:
–Treat Adjacent Spinal Regions That May be Restricted
–Correct, if possible, greater postural deformities
Exercise:
–Strengthen musculature that crosses the segment or joint
Postural Reeducation

103
Q

How to treat Localized Hypermobility syndrome #2

A

Bracing
–No Bracing Without Exercise at Same Time

Prolotherapy
–Takes Two to Four Months to Work
Surgical Fusion
–Treatment of Last Resort – Patient Must Meet the Criteria for Surgical Level Instability

104
Q

Ehlers-Danlos Syndrome

A

A group of inherited disorders that affect connective tissue due to defects in collagen production
There are Eleven Subtypes

105
Q

What are other names for Ehlers-Danlos Syndrome type III?

A

Hypermobility type III

Benign hypermobility syndrome

Arthrochalasis multiplex congenita

106
Q

Symptoms of Ehlers-Danlos Syndrome type III

A

loose unstable joints

chronic joint pain

107
Q

Signs & symptoms of Ehlers-Danlos Syndrome classical type (I &II)

A

Highly Elastic, Velvety Skin
Fragile Skin that Bruises and Tears Easily
Slow and Poor Wound Healing Leading to Scarring
Non-cancerous fibrous growths on pressure areas such as elbows and knees
Fatty Growths on Shins & Forearms
Loose Joints, Prone to Dislocation, Delayed Development of Large-Motor Skills

108
Q

Signs & symptoms of Ehlers-Danlos Syndrome vascular type (IV)

A

Fragile Blood Vessels and Organs that are Prone to Rupture
Thin, Fragile Skin that Bruises Easily
Veins Visible Beneath the Skin
Distinctive Facial Features Including Protruding Eyes, Thin Nose & Lips, Sunken Cheeks and Small Chin
Loose Joints Usually Limited to Fingers & Toes

109
Q

Signs & symptoms of Ehlers-Danlos Syndrome kyphoscoliosis (VI)

A

–Progressive Scoliosis
–Fragile Eyes That are Easily Damaged
–Severe, Progressive Muscle Weakness

110
Q

Signs & symptoms of Ehlers-Danlos Syndrome arthrochalasia (VII A & B)

A

–Very loose joints and dislocations, involving hips, which may delay development of large motor skills
–Stretchy Skin that’s Prone to Bruising
–Early Onset Arthritis
–Increased Risk of Osteoporosis

111
Q

Signs & symptoms of Ehlers-Danlos Syndrome dermatosparaxis (VII C)

A

–Extremely Fragile and Sagging Skin
–Loose Joints, may see Large Motor Delay

112
Q

List the incidences of Ehlers-Danlos Syndrome subtypes

A

Type III: 1 in 10-15,000

Typer I & II: 1 in 20-40,000

Type IV: 1 in 100-200,000

Type VI: 60 cases ever reported

Type VII A & B: 30 cases ever reported

Typer VII C: 10 cases ever reported

113
Q

Ehlers-Danlos Syndrome diagnosis

A

Genetic test, skin biopsy, cardiac ultrasound

114
Q

Ehlers-Danlos Syndrome complications

A

Prominent Scarring
–Difficulty with Surgical Wounds Healing
–Chronic Joint Pain
–Early Onset Arthritis
–Premature Aging with Sun Exposure

115
Q

Ehlers-Danlos Syndrome more complications

A

–Rupture of Major Blood Vessels, Intestines, Uterus.
–Eye Problems
–Osteoporosis
–Premature Delivery of Fetus
–Premature Rupture of Fetal Membranes

116
Q

Ehlers-Danlos Syndrome self care

A

–Avoid Injury
–Use Protective Gear
–Reduce Clutter
–Use Assistive Devices
–Wear Sunscreen

117
Q

Ehlers-Danlos Syndrome treatment

A

–OMT: Same as for benign hypermobility
–Stabilization Exercises
–Vitamin C (May help)

118
Q

List the possible temporomandibular joint dysfunction

A

Joint Disease
Dental Malocclusion
Dysfunction of Muscles of Mastication
Head Carriage
Cranial Somatic Dysfunction
Psychological Issues

119
Q

History of Degenerative diseases

A

Insidious onset, age over 50 years

**requires imaging

120
Q

List the possible degenerative diseases

A

Cervical Spondylosis
Diffuse Idiopathic Skeletal Hyperostosis
Osteoarthritis – Shoulder
Osteoarthritis - TMJ

121
Q

What is common in patients with cervical disc disease (cervical spondylosis)?

A

Headache

122
Q

For cervical spondylosis headache, what is the right way to declare the etiology?

A

Declare etiology of headache based on x-ray AND physical findings

123
Q

What is DISH?

A

Diffuse Idiopathic Skeletal Hyperostosis

124
Q

Facts about DISH #1

A

In the cervical spine it can result in Ossification of the Posterior Longitudinal Ligament
More common in persons of Japanese descent

125
Q

Facts about DISH #2

A

Symptoms range from asymptomatic –to–

quadriplegia from minor injury

Long Track Symptoms & Signs usually develop gradually over a period of years

126
Q

DISH exhibits…

A

Candle wax osteophytes

127
Q

DISH is related to what other disease?

A

Diabetes Mellitus Type II

pts need to have fasting blood sugar tested

128
Q

Thoracic Outlet Syndrome

A

Insidious onset, it may also follow trauma

129
Q

Syndromes caused by Thoracic Outlet Syndrome

A

Anterior Scalene Syndrome
Costo-clavicular Syndrome
Pectoralis Minor Syndrome
Somatic Dysfunction
–Cervical
–1st & 2nd Rib
–Clavicle

130
Q

Exposure to the toxin may be:

A

Vocational
Avocational
Incidental

131
Q

Etiologies of metabolic disorders

A

Nutritional
–Ingestion
–Digestion
–Excretion
Endocrine

132
Q

What laboratory screening test should be perform in pts with toxic and metabolic disorders?

A

–CBC
–Urinalysis
–Blood Chemistries: Glucose, BUN, Creatinine, Electrolytes, Calcium, Protein, Albumin, Globulin, Bilirubin, Alkaline Phosphatase, AST, ALT, TSH, T3/T4

133
Q

What are some metabolic disorders?

A

Hyperthyroidism

Hypothyroidism

Hypokalemia

Hypomagnesemia

134
Q

Hyperthyroidism

A

Muscle Weakness & Atrophy

135
Q

Hypothyroidism

A

Brisk reflex contraction with slow relaxation

136
Q

Hypokalemia

A

Muscle Weakness, Cramping, Fasciculations

137
Q

Hypomagnesemia

A

Weakness, Tetany, Carpopedal Spasm, Positive Chvostek Sign

138
Q

Chvostek Sign

A

Facial muscles involuntarily contract when the facial nerve is percussed

139
Q

Failed Sugeries

A

Cervical Spine
Dental
Ophthalmologic
Otolaryngologic

140
Q

Referred pain FROM Head & Neck

A

Breast Pain
–C5/C6 nerve root {myotomal pain}
Precordial Pain
–C5/C6 nerve root {myotomal pain}
Facial Pain (Trigeminal Neuralgia)

141
Q

Referred pain TO Neck & Head

A

Cardiac Pain
Complex Regional Pain Syndrome

(Reflex Sympathetic Dystrophy Syndrome)

(Barre’-Leiou Syndrome)

Dental Pain
Myofascial Trigger Points
Occipital Neuralgia
Ocular Pain

OMM T2 Exam2 (2 decks)

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