Neck And Back Pain

Question 1

If you suspect a disk herniation what imaging is indicated?

Answer 1

If the patient has no risk factors in the H/P and PE for serious disease other than sciatica, treat conservatively and do not perform any diagnostic testing
- neuro deficit: pain radiographs for other causes
- severe progressive neuro deficit with serious condition: urgent MRI
- - not rapid/severe: routine MRI

Question 2

What to do if you suspect cauda equina and you think its from a tumor? (Not imaging)

Answer 2

When clinically suspected, especially if due to a tumor, treat the patient with dexamethasone 10mg IV before any other testing.

Question 3

Imaging for suspected cauda equina

Answer 3

Suspect tumor, MRI w/ gadolinium
- image entire spine
- 10% will have vertebral metastases and and additional silent epidural metastases

Suspect from disk herniation MRI localized to the lumbosacral spine

Question 4

When should you suspect transverse myelitis?

Answer 4

Presents like cauda equina/epidural compression syndrome with a NEGATIVE MRI

Question 5

Back pain with suspition of infection, what is the gold standard imaging?

Answer 5

MRI with contrast

Question 6

What should you find with vertebral osteomyelitis? Timeline, labs

Answer 6

Prolonged symptoms >3mo

Labs: elevated CRP, +/-leukocytosis
POS BC in 40%

Question 7

Findings with diskitis?

Answer 7

• Unremitting back/neck pain
• Awakens at night
• Not relieved by rest or analgesics
• Fever in 60-70%
• Variable neuro deficits

Question 8

What is the triad for spinal epidural abscess?
How accurate is it?

Answer 8

Traid:
- severe back pain
- fever
- neurologic deficit

Only seen in 8-13%

Question 9

Spinal epidural abscess is often co-infected witj?

Answer 9

Vertebral osteomyelitis
Diskitis

Question 10

Risk factors for spinal epidural abscess?

Answer 10

IV drug use
Immunocompromised
ETOH abuse
Spine surgery
Distal infection
DM
Indwelling catheter
Recent spine fracture
Chronic renal failure
Cancer

Question 11

Cauda equina fits into what category?

Answer 11

Epidural compression syndrome

Question 12

What is the earliest/MC finding of cauda equina?

Answer 12

Urinary retention of >500mL alone or incombination with two of the following:
- bilateral sciatica
- subjective urinary retention
- rectal incontinence sx

Question 13

What is the most important predictor of MRI confirmed cauda equina compression?

Answer 13

Urinary retention is the most important predictor of MRI confirmed cauda equina syndrome

Question 14

What is the MC sensory deficit of cauda equina?

Answer 14

Saddle anesthesia
- occurs over the buttocks, posteriorsuperior thighs, and perineal regions

Question 15

Why does radiology always ask about rectal tone in cauda equina?

Answer 15

It is decreased in 60-80%

Question 16

What is a positive straight leg test?

Answer 16

Radicular pain radiating below the knee of the affected leg

Question 17

Why test straight leg test?

Answer 17

Screening test for herniated disk

68-80% sensitive for a L4-L5 or L5-S1 herniated disk

Question 18

What is a highly sensitive but not specific test for nerve root compression by herniated disk?

Answer 18

Crossed straight leg raise test
- radicular pain down the unaffected leg with straight leg raise.

Question 19

C1-C2 compression presents in what region?

Answer 19

Neck/scalp

Question 20

C4-C5 presentation ?

Answer 20

Complaint: neck, shoulder, arm
Sensory deficit: shoulder
Motor weakness: infraspinatous, deltoid, bicpeps
Reflex: reduced biceps reflex

Question 21

C5-C6 presentation?

Answer 21

Complaint: neck, shoulder, upper medial scalp, proximal forearm, thumb, index finger
Sensory deficit: thumb, index finger, lateral forearm
Motor weakness: deltoid, biceps, pronator teres, wrist extension
Altered reflex: reduced biceps and brachioradialias reflex

Question 22

C6-C7 presentation?

Answer 22

Complaint: neck, posterior arm, dorsum proximal forearm, chest, medial 1/3 of scapula, middle finger
Sensory deficit: middle finger, forearm
Motor weakness: triceps, pronator teres
Altered reflex: reduced triceps reflex

Question 23

C7-T1 presentation?

Answer 23

Complaint: neck, posterior arm, ulnar side of forearm, medial inferior scapular border, medial hand, ring and little finger
Sensory deficit: ring and little fingers
Motor weakness: triceps, flexor carpi ulnaris, hand intrinsics
Altered reflex: reduced triceps reflex