Evaluation of Neck and Back Pain Flashcards
outline which muscles, sensroy changes, and reflexes are affected by C5, C6, C7, C8, L4, L5, S1 radiculopathies
At the Cspine, the nerve root travels ___ the pedicle of the corresponding vertebra.
C8 travels __ THE ___ pedicle
In the T/L spine, the nerve root travels ___ the pedicle of the corresponding vertebra.
The T1 nerve root travels __ the T1 pedicle.
At the Cspine, the nerve root travels ABOVE the pedicle of the corresponding vertebra.
C8 travels OVER THE T1 pedicle
In the T/L spine, the nerve root travels BELOW the pedicle of the corresponding vertebra.
The T1 nerve root travels below the T1 pedicle.
• Lumbar radiculopathies: pain radiating from back to leg, ____ pain exacerbated by flexion, sitting, coughing, straining
Provocative testss?
Provocative tests include Spurling’s Sign and Lasegue’s Sign
Straight leg (laseagues)= sciatic pain elicitor.
pain radiating from back to leg, sciatica pain exacerbated by flexion, sitting, coughing, straining
Investigations:
If L5, differentiate from peroneal nerve palsy:
peroneal nerve palsy will have no radicular pain, no straight leg pain, no weakness of foot inversion→ can confirm peroneal nerve palsy with EMG
reflexes:
S1= __ reflex
L3-4= __
L5= __ jerk
S1= achilles reflex
L3-4= knee
L5= ankle jerk
Cervical Spondylotic Myelopathy (CSM)
Definition: progressive degeneration process of cervical spine leading to canal ___.
Hallmark: cord dysfunction secondary to combination of ___ ___ and ___ compromise.
Natural history: 75% stepwise progressive decline, 20% slow/steady decline, 5% rapid decline
Mechanism: age-related disc ___ leading to height loss/___→ bone ___→ ___ induction→ disc degeneration→ facet __ + ligamentous ___→ instability→ dynamic and static __ + ___ compromise
Cervical Spondylotic Myelopathy (CSM)
Definition: progressive degeneration process of cervical spine leading to canal stenosis.
Hallmark: cord dysfunction secondary to combination of mechanical compression and vascular compromise.
Natural history: 75% stepwise progressive decline, 20% slow/steady decline, 5% rapid decline
Mechanism: age-related disc dehydration leading to height loss/narrowing→ bone contact→ osteophyte induction→ disc degeneration→ facet hypertrophy + ligamentous laxity→ instability→ dynamic and static compression + vascular compromise
Sensory pattern loss of Cervical spondylotic myelopathy, motor function losses
sensory disturbances happen first: decreased fine touch in hands, proprioceptive and vibration sense deficits
Motor function follows → Upper Motor Neuron Signs/UMN signs(Hypertonicity, hyperreflexia, primitive reflexes). Sphincter dysfunction.
Symptoms: unsteady gait, clumsy/weak hands, leg weakness/stiffness, urinary urgency, should/arm pain, stiff neck, hyperactive reflexes, occipital headache.
Management: surgery is almost always required in all cases (mild to moderate)
Lumbar Stenosis
Etiology: congenital ___ of spinal canal + ___ changes (herniated disc, hypertrophied facet joints, ligamentum flavum)
Risk factors: __ __, __, __
Symptoms: gradual progressive bilateral back and leg pain with __/__ that is relieved by __/__ down
Investigations: MRI
Management:
- Conservative: __, __
- Surgery: __ with root decompression +/- __
Lumbar Stenosis
Etiology: congenital narrowing of spinal canal + degenerative changes (herniated disc, hypertrophied facet joints, ligamentum flavum)
Risk factors: older age, obesity, smoking
Symptoms: gradual progressive bilateral back and leg pain with standing/walking that is relieved by sitting/lying down
Investigations: MRI
Management:
• Conservative: NSAIDs, analgesia
• Surgery: laminectomy with root decompression +/- fusion
Neurogenic Claudication
Description: usually __ leg pain and dysesthesia spreading from back to lower extremities on __ or __
Relieved by __ (__ posture) with bent knees and hips
Neurogenic Claudication
Description: usually bilateral leg pain and dysesthesia spreading from back to lower extremities on walking or standing
Relieved by sitting (flexed posture) with bent knees and hips
differentiate neurogenic claudication from vascular claudication picture
Differentiate from vascular claudication: VC has calf cramping, no dysesthesias, relieved by standing still, does not depend on back posture.
outlien which nerve roots are responsible for
- hip flexion
- hip extension
- knee extension
- knee flexion
- ankle dorsiflexion
- ankle plantar flexion
- great toe flexor
outline which nerve roots are repsonsible for
- shoulder abduction
- shoulder adduction
- elbow flexion
- elbow extension
- wrist flexion and extension
- finger glexion
- finger extensino
- finger abduction
- abductor pollicis brevis
VINDICATE causes for neck and back pain
V; vascular
I: infection/inflammatory
N: neoplastic
D: degeneration/drugs
I: idiopathic and iatrogenic
C: congenital
A: autoimmune
T: traumatic
E: endorcine/metabolic
Background on Working Up Lower Back Pain
Visit #1
Pain diagram + STarT back tool
Rule out red flags
- If none, reassure + stay active + analgesics
- if yes, Imaging (MRI) +/- referral to surgery, neurology, rheumatology
Red flags for backpain
- cauda equina syndome
- severe unremitting worsening pain
- significant trauma
- weight loss, fever history, cancer
- use of IV drugs/steroids
- widespread neurological signs
- age 65+ with first episode of severe back pain
surgical indications
- myelopathy (recall that cervical spondylotic myelopathy is almost always surgical and progressive)
- radiculopathy IF there’s intractable pain unresponseive to course of conservative therapy, progressive neurological deficit, or significant, non progressive neurological deficit
- aucte cauda equina syndrome
