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Clin Path II > Neck And Arm Pain > Flashcards

Neck And Arm Pain Flashcards

1
Q

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?

A

Is not necessarily the cause

  • can either careful monitor on therapeutic trial or order ancillary studies if there is a greater concern
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2
Q

What ancillary studies should you order if you suspect disease?

A
  • 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)
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3
Q

What are red flags for disease from history?

A
  • 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
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4
Q

What are some red flags form the physical?

A
  • 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
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5
Q

What are some of the red flags from ancillary studies?

A
  • Elevated ESR or CRP

- anemia

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6
Q

What is the natural history/ prognosis for most injury conditions?

A
  • 80-90% have pain resolution within 8 weeks

- at least 40% will relapse within about 1 year

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7
Q

When can you do a low index neuro screen?

A
  • 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
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8
Q

What is the neuro screen for neck pain only?

A
  • sensory (palm and dorsum)
  • biceps and triceps DTR
  • muscle test (hand grip and perhaps deltoid)
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9
Q

If you DO NOT suspect nerve damage in a patient with neck pain ONLY after TRAUMA, what is your ddx?

A

Pathoanatomical

  • sprain
  • strain
  • facet syndrome
  • disc derangement
  • fracture

Biomechanical

  • joint dysfunction (segmental dysfunction)
  • muscle spasm
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10
Q

If you DO NOT suspect nerve damage in a patient with neck pain ONLY and NO TRUAMA what is your ddx?

A

Pathoanatomical

  • facet syndrome
  • disc derangement
  • sprain
  • strain

Biomechanical

  • joint dysfunction (segmental dysfunction)
  • myofascial pain syndrome/spasm
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11
Q

What is the prevalence of facet syndrome in patient with chronic pain?

A

Estimated 36-67% of patients with persistent neck pain

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12
Q

What are the 5 ddx for neck and arm symptoms?

A

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
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13
Q

If you believe there are separate lesions long the kinetic chain, what is the ddx?

A

Neck lesion +

  • GH joint/ rotator cuff
  • spasm/ MFTP upper arm
  • elbow lesion
  • forearm MFTP
  • wrist lesion
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14
Q

What is the arm squeeze test? What are SN and SP?

A
  • 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%
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15
Q

What are the 5 clues for NR lesions?

A
  • 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
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16
Q

What is the A list for radicular pain?

A
  • osteophyte spurs (“hard disc” due to DJD)
  • soft disc herniation
  • spinal canal stenosis
17
Q

B list for radicular pain?

A
  • structural instability (trauma, inflammatory arthritis, degeneration)
  • tumor/ SOL (including ossification of the posterior longitudinal ligament)
  • infection (disc, bone, meninges)
  • NR adhesions
  • trauma to NR
18
Q

What are MOI for damaging the NR?

A
  • compression
  • hyperextension (especially with rotation)
  • lateral flexion with shoulder depression (think brachial plus first, then NR)
  • hyperflexion (not common)
  • arm traction (brachial plexus only)
19
Q

C list for NR damage?

A
  • disc derangement
  • facet syndrome
  • joint dysfunction

*if there ARE significant neuro deficits, these are even less likely

20
Q

Whenever there is evidence of a C/S NR lesion, you must … ?

A

Check to see if there is also spinal cord involvement as well

21
Q

A list for cord damage?

A
  • disc herniation
  • spinal stenosis

*NOT OSTEOPHYTE

22
Q

B list for cord damage?

A
  • tumors
  • structural instability (especially at atlas)
  • cord traumatic injury (E.G. hyperflexion injury)
  • fracture/dislocation
  • cord adhesions
  • infection
23
Q

What are indications for radiographs?

A
  • 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)
24
Q

Indications for MRI in DISC CASES after radiographs

A
  • 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
25
Q

What are MOI for traumas that cause nervous tissue damage?

A
  • compression
  • hyperextension (especially with rotation)
  • lateral flexion with shoulder depression (think brachial plexus first, then NR)
  • hyperflexion (not common)
  • arm traction (brachial plexus only)
26
Q

What is the best clue from the exam for a strain

A

Isometric contraction of neck muscles is painful and may be weak

27
Q

How do you differentiate sprain from strain?

A
  • 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
28
Q

What are indications for radiographs in a patient who had trauma?

A
  • > 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)
29
Q

If there is a CAD (cervical acceleration-deceleration) injury, what Xrays should you order?

A
  • 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
30
Q

What are 5 tests for TOS?

A
  • adson’s test
  • hyperabduction test
  • costoclavicular test
  • Roos test
  • Tinel’s test
31
Q

What is the in office treatment for TOS?

A

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

32
Q

What are causes of symptoms in the arm?

A
  • deep referred pain
  • radicular
  • cervical spinal cord
  • neural compromise
  • lesions along the kinetic chain
33
Q

How d you evaluate and train deep neck stabilizers?

A

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

Clin Path II (18 decks)

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