Neck And Arm Pain Flashcards
If your patient has no red flags, then a disease is not likely. If they do have red flags, a disease (is/is not necessarily) the cause and you should do what?
Is not necessarily the cause
- can either careful monitor on therapeutic trial or order ancillary studies if there is a greater concern
What ancillary studies should you order if you suspect disease?
- Radiograph (or advanced if necessary)
- ESR (20-50) and/or CRP
- CBC
- Blood Chemistry Pane (e.g. ALP, Ca, Protein)
- special blood tests (e.g. anti-CCP/RF)
What are red flags for disease from history?
- prior history of cancer
- unexplained weight loss
- unvarying symptoms
- fever/chills
- recent bacterial infection/ hx of recurrent infection
- pain unimproved with a month fo treatment
- neck pain with urinary retention/incontinence
- multiple joint involvement
- history of long-term corticosteroid use (cause weakness of transverse ligament leading to instability in neck, or osteoporosis)
- chronic shoulder pain in smoker over 50-60
- recent infection + fever+ neck stiffness
What are some red flags form the physical?
- Palpable mass
- diffuse cape-like distribution of pain/temp loss over one or both shoulders
- Horner’s syndrome
- neck/arm pain with neurological deficits in patients over 50-60
- neck pain plus nuchal rigidity
What are some of the red flags from ancillary studies?
- Elevated ESR or CRP
- anemia
What is the natural history/ prognosis for most injury conditions?
- 80-90% have pain resolution within 8 weeks
- at least 40% will relapse within about 1 year
When can you do a low index neuro screen?
- no radiation pain into an extremity or head
- specific denial of NTW in any of the 4 extremities
- no headache or crania nerve symptoms
- no recent significant trauma
- patient under 50 years old
What is the neuro screen for neck pain only?
- sensory (palm and dorsum)
- biceps and triceps DTR
- muscle test (hand grip and perhaps deltoid)
If you DO NOT suspect nerve damage in a patient with neck pain ONLY after TRAUMA, what is your ddx?
Pathoanatomical
- sprain
- strain
- facet syndrome
- disc derangement
- fracture
Biomechanical
- joint dysfunction (segmental dysfunction)
- muscle spasm
If you DO NOT suspect nerve damage in a patient with neck pain ONLY and NO TRUAMA what is your ddx?
Pathoanatomical
- facet syndrome
- disc derangement
- sprain
- strain
Biomechanical
- joint dysfunction (segmental dysfunction)
- myofascial pain syndrome/spasm
What is the prevalence of facet syndrome in patient with chronic pain?
Estimated 36-67% of patients with persistent neck pain
What are the 5 ddx for neck and arm symptoms?
Nerve involvment
- cord lesions
- nerve root epsilon’s
- peripheral nerve lesions
No nerve invovlent
- deep referred pain (like MFTP)
- separate lesions along the kinetic chain
If you believe there are separate lesions long the kinetic chain, what is the ddx?
Neck lesion +
- GH joint/ rotator cuff
- spasm/ MFTP upper arm
- elbow lesion
- forearm MFTP
- wrist lesion
What is the arm squeeze test? What are SN and SP?
- helps differentiate arm pain from shoulder vs neck
- squeeze the patients mid upper arm, then the AC and anterolateral-subacromial areas
- POSITIVE TEST = if the problem is from the neck and there is nerve involvement, the arm will hurt worse (at least 3/10 more on pain scale)
- SN = 97%, SP = 97%
What are the 5 clues for NR lesions?
- pain (quality, dermatomal, greater than neck pain)
- paresthesia (especially dermatomal)
- SMR deficits
- change in arm symptoms by any of the big 5 (C/S compression, distraction, ULTT, shoulder abduction, valsalva)
- reproduction of arm symptoms with AROM or any load to the c-spine
What is the A list for radicular pain?
- osteophyte spurs (“hard disc” due to DJD)
- soft disc herniation
- spinal canal stenosis
B list for radicular pain?
- structural instability (trauma, inflammatory arthritis, degeneration)
- tumor/ SOL (including ossification of the posterior longitudinal ligament)
- infection (disc, bone, meninges)
- NR adhesions
- trauma to NR
What are MOI for damaging the NR?
- compression
- hyperextension (especially with rotation)
- lateral flexion with shoulder depression (think brachial plus first, then NR)
- hyperflexion (not common)
- arm traction (brachial plexus only)
C list for NR damage?
- disc derangement
- facet syndrome
- joint dysfunction
*if there ARE significant neuro deficits, these are even less likely
Whenever there is evidence of a C/S NR lesion, you must … ?
Check to see if there is also spinal cord involvement as well
A list for cord damage?
- disc herniation
- spinal stenosis
*NOT OSTEOPHYTE
B list for cord damage?
- tumors
- structural instability (especially at atlas)
- cord traumatic injury (E.G. hyperflexion injury)
- fracture/dislocation
- cord adhesions
- infection
What are indications for radiographs?
- moderate to high load trauma (R/O fractures & structural instability)
- red flags for disease
- cord signs/symptoms (then MRI)
- radicular signs/symptoms (weaker clue)
- nonresponsive cases (perhaps after 1 months or more of failed care)
Indications for MRI in DISC CASES after radiographs
- lowest: signs/symptoms of radiculitis
- moderate: only if there are deficits
- highest: only if there is suspicion of myelopathy, progressive deficit (motor especially), non-responsive to conservative care (should be 50% better in 3-4 weeks and 100% better in 3-4 months), presurgical exam
What are MOI for traumas that cause nervous tissue damage?
- compression
- hyperextension (especially with rotation)
- lateral flexion with shoulder depression (think brachial plexus first, then NR)
- hyperflexion (not common)
- arm traction (brachial plexus only)
What is the best clue from the exam for a strain
Isometric contraction of neck muscles is painful and may be weak
How do you differentiate sprain from strain?
- muscle testing with be painful or weak for strains but not for sprain. Sprain may have pain at “set”
- PROM is painless for strain unless the muscle is stretched and is painful/limited for sprain often in the mid range
- AROM is painful and limited for both. Strain tends to be painful in one plane whereas sprain may be painful in different directions
- orthos may be painful for strain if they load or stretch the muscle and painless for sprain unless the ligament is stretched
What are indications for radiographs in a patient who had trauma?
- > 65
- dangerous MOI
- paresthesia in extremities
- painful, distracting injury somewhere else in the body
- altered level of alertness
- evidence of intoxication
- patient with known vertebral disease (RA, DOwns, AS, stenosis, fused segments, Marfans, os odontoideum, klippel-feel syndrome, marquio syndrome)
If there is a CAD (cervical acceleration-deceleration) injury, what Xrays should you order?
- Davies series: a complete 7 view study (AP, APOM, lateral, 2 obliques, flex/extension)
- flexion and extension studies only taken AFTER static films in severe trauma
What are 5 tests for TOS?
- adson’s test
- hyperabduction test
- costoclavicular test
- Roos test
- Tinel’s test
What is the in office treatment for TOS?
Stretch
- scalenes, pec major, levator scap, suboccipitals
STM
- PIR, CRAC, pin & stretch (ART), IASTM, “nerve flossing”
Correct postural analysis
- forwards head carriage, rounded/dropped shoulder, upper cross syndrome
What are causes of symptoms in the arm?
- deep referred pain
- radicular
- cervical spinal cord
- neural compromise
- lesions along the kinetic chain
How d you evaluate and train deep neck stabilizers?
Test
- Jull test
- janda neck flexion test
Exercises
- seated chin retraction
- supine chin retraction
- prone chin retraction
- Squeeze baseball under chin
- rock ball up and down with forehead against wall
- supine with neck and head over the table holding neck flexion
