Neuro Flashcards

Question

5 stages of a migraine

Answer 1

These stages are not typical of everyone and they will vary between patients. Some patients may only experience one or two of the stages. The prodromal stage can involve several days of subtle symptoms such as yawning, fatigue or mood changes prior to the onset of the migraine. * ***Premonitory*** or ***prodromal*** stage (can begin 3 days before the headache) * ***Aura*** (lasting up to 60 minutes) * ***Headache*** stage (lasts 4-72 hours) * ***Resolution*** stage (the headache can fade away or be relieved completely by vomiting or sleeping) * ***Postdromal*** or ***recovery*** phase

Answer 2

Often patients will go to a dark quiet room and sleep. Options for medical management are: * ***Paracetamol*** * ***oral Triptans*** (e.g. sumatriptan 50mg as the migraine starts) * ***NSAIDs*** (e.g ibuprofen or naproxen) * ***Antiemetics*** if vomiting occurs (e.g. metoclopramide)

Answer 3

They are ***5HT receptors agonists*** (***serotonin receptor agonists***) Triptans are used to abort migraines when they start to develop They act on: * Smooth muscle in arteries to cause vasoconstriction * Peripheral pain receptors to inhibit activation of pain receptors * Reduce neuronal activity in the central nervous system CI - IHD, coronary spasm, uncontrolled hypertension, recent lithium, SSRIs, ergot use

Answer 4

headache diary - identify and then avoid the triggers, also useful in demonstrating the response to treatment. * ***Propranolol*** * ***Topiramate*** (this is teratogenic and can cause a cleft lip/palate so patients should not get pregnant) * ***Amitriptyline*** ***Acupuncture*** is an option recommended by NICE recommend for the treatment of migraines. It is reported to be as effective as prophylactic medications. Supplementation with vitamin B2 (***riboflavin***) may reduce frequency and severity. In migraine specifically triggered around menstruation, prophylaxis with ***NSAIDs*** (e.g. ***mefanamic acid***) or ***triptans*** (***frovatriptan*** or ***zolmitriptan***) can be used as a preventative measure. botulinum injections are a last resort Migraines tend to get better over time and people often go into remission from their symptoms.

Answer 5

they come in clusters of attacks and then disappear for a while. For example, a patient may suffer 3 – 4 attacks a day for 4-12 weeks followed by a pain-free period lasting months to 1-2 years. Attacks last between 15 minutes and 3 hours. it can be chronic as well rather than episodic. more common in males and smokers. Attacks can be triggered by things like alcohol, strong smells and exercise. Cluster headaches are often described as one of the most severe and intolerable pains in the world. They are sometimes referred to as “***suicide headaches***” due to the severity of the pain. Symptoms are typically all **unilateral**: * Red, swollen and watering eye (lacrimation) * Pupil constriction (miosis) * Eyelid drooping (ptosis) * Nasal discharge (rhinorrhoea) * Facial sweating (flushing)

Answer 6

**Acute management:** * Triptans (e.g. sumatriptan injected subcutaneously) * High flow 100% oxygen for 15-20 minutes via non-rebreathable maks(can be given at home) **Prophylaxis options:** * avoid triggers eg alcohol * Verapamil * Lithium * corticosteroids such as prednisolone (a short course ONLY for 2-3 weeks to break the cycle during clusters)

Answer 7

* Head injury * Hypertension * Aneurysms * Ischaemic stroke can progress to haemorrhage * Brain tumours * Anticoagulants such as warfarin

Answer 8

**Sudden onset headache** is a key feature. They can also present with: * Seizures * Weakness * Vomiting * Reduced consciousness * Other sudden onset neurological symptoms

Answer 9

**Sudden onset headache** is a key feature. They can also present with: * Seizures * Weakness * Vomiting * Reduced consciousness * Other sudden onset neurological symptoms

Answer 10

When someone has a score of 8 or below then you need to consider securing their airway as there is a risk they are not able to maintaining it on their own.

Answer 11

GCS is used to assess level of consciousness **Eyes** * Spontaneous = 4 * Speech = 3 * Pain = 2 * None = 1 **Verbal response** * Orientated = 5 * Confused conversation = 4 * Inappropriate words = 3 * Incomprehensible sounds = 2 * None = 1 **Motor response** * Obeys commands = 6 * Localises pain = 5 * Normal flexion = 4 * Abnormal flexion = 3 * Extends = 2 * None = 1

Answer 12

Subdural haemorrhage is caused by rupture of the ***bridging veins*** in the outermost meningeal layer. They occur between the ***dura mater*** and ***arachnoid mater***. On a CT scan they have a ***crescent shape*** and are not limited by the ***cranial sutures*** (they can cross over the sutures). Subdural haemorrhages occur more frequently in elderly or alcoholic patients. These patients have more ***atrophy*** in their brains making vessels more likely to rupture.

Answer 13

Extradural haemorrhage is usually caused by rupture of the ***middle meningeal artery*** in the ***temporo-parietal regio***n. It can be associated with a fracture of the ***temporal bone***. It occurs between the ***skull*** and ***dura mater***. On a CT scan they have a ***bi-convex shape*** and are limited by the ***cranial sutures*** (they can’t cross over the sutures). The typical history is a young patient with a traumatic head injury that has an ongoing headache. They have a period of improved neurological symptoms and consciousness followed by a rapid decline over hours as the haematoma gets large enough to compress the intracranial contents.

Answer 14

Intracerebral haemorrhage involves bleeding into the brain tissue. It presents similarly to an ischaemic stroke. These can be anywhere in the brain tissue: * Lobar intracerebral haemorrhage * Deep intracerebral haemorrhage * Intraventricular haemorrhage * Basal ganglia haemorrhage * Cerebellar haemorrhage They can occur spontaneously or as the result of bleeding into an ischaemic infarct or tumour or rupture of an aneurysm.

Answer 15

Subarachnoid haemorrhage involves bleeding in to the ***subarachnoid space***, where the ***cerebrospinal fluid*** is located, between the ***pia mater*** and the ***arachnoid membrane***. This is usually the result of a ruptured ***cerebral aneurysm***. subarachnoid haemorrhage has a very high ***mortality*** and ***morbidity***. It is very important not to miss the diagnosis and you need to have a low suspicion to trigger full investigations. It needs to be discussed with the ***neurosurgical unit*** with a view to surgical intervention. 80% caused by berry aneursym rupture

Answer 16

* Immediate CT head to establish the diagnosis * Check FBC and clotting * Admit to a specialist stroke unit * Discuss with a specialist neurosurgical centre to consider surgical treatment * Consider intubation, ventilation and ICU care if they have reduced consciousness * Correct any clotting abnormality * Correct severe hypertension but avoid hypotension

Answer 17

The typical history is a sudden onset occipital headache that occurs during strenuous activity such as weight lifting or sex. This occurs so suddenly and severely that it is known as a “***thunderclap headache***”. It is described like being hit really hard on the back of the head. Other features are: * Neck stiffness * Photophobia * Vision changes * Neurological symptoms such as speech changes, weakness, seizures and loss of consciousness They are particularly associated with ***cocaine*** and ***sickle cell anaemia***.

Answer 18

* Hypertension * Smoking * Excessive alcohol consumption * Cocaine use * Family history Subarachnoid haemorrhage is more common in: * Black patients * Female patients * Age 45-70 It is particularly associated with: * Cocaine use * Sickle cell anaemia * Connective tissue disorders (such as Marfan syndrome or Ehlers-Danlos) * Neurofibromatosis * Autosomal dominant polycystic kidney disease

Answer 19

Immediate CT head is required. Blood will cause ***hyperattenuation*** in the ***subarachnoid space***. if CT head negative - then LP is done \>12 hrs AFTER headache onset to check for: CSF ***Red cell count*** will be raised. If the cell count is decreasing in number over the samples, this could be due to a traumatic lumbar puncture. *CSF **Xanthochromia*** (the yellow colour of CSF caused by bilirubin) ***Angiography*** (CT or MRI) can be used once a subarachnoid haemorrhage is confirmed to locate the source of the bleeding.

Answer 20

Patients should be managed by a ***specialist neurosurgical unit***. Patients with reduced consciousness may require intubation and ventilation. refer to neurosurgery immediately nimodipine surgery: endovascular coiling vs surgical clipping ***Surgical intervention*** may be used to treat aneurysms. The aim is to repair the vessel and prevent re-bleeding. This can done by ***coiling***, which involves inserting a catheter into the arterial system (taking an “***endovascular approach***”), placing platinum coils into the aneurysm and sealing it off from the artery. An alternative is ***clipping***, which involves cranial surgery and putting a clip on the aneurysm to seal it. ***Nimodipine*** is a calcium channel blocker that is used to prevent ***vasospasm***. ***Vasospasm*** is a common complication that can result in brain ischaemia following a subarachnoid haemorrhage. ***Lumbar puncture*** or insertion of a ***shunt*** may be required to treat ***hydrocephalus***. ***Antiepileptic*** medications can be used to treat ***seizures***. Supportive care as part of a multi-disciplinary team is important with good nursing, nutrition, physiotherapy and occupational therapy involved during the initial stages and recovery.

Answer 21

headache - chronic, progrssive, worse on walking, lying, bending forward, coughing. vomiting, papilloedema, seizures, localiszing signs, odd behaviour. LP is CI until after imaging

Answer 22

**acute glaucoma** - typically elderly, long sighted. unilateral pain arnd one eye radiating to forehead with reduced vision, visual haloes and a red congested eye. seek expert help at once. if delay in tx of \> 1hr is likely, give eye drops (timolol maleate +/- pilocarpine) and PO acetazolamide GCA - subacute headache, raised ESR. exclude in all \>50 yr. prompt diagnosis and steroids to avoid blindness acute episode of cluster headahce

Answer 23

COCP CI in women with migraine + aura low dose cocp can be used in those without aura prganancy - migraine often improves; if not get help - greater risk of pre-eclampsia. paracetamol 1st line. don's use aspirin if breast feeding. antiemetic choic - cyclizine or promethazine

Answer 24

inflammation of the meninges usually due to a bacterial or a viral infection. The most common causes of bacterial meningitis in children and adults is ***Neisseria meningitidis*** (***meningococcus***) and ***Streptococcus pneumoniae*** (***pneumococcus***). less commonly H. infleunzae In ***neonates*** the most common cause is ***Group B Streptococcus*** (***GBS***). GBS is usually contracted during birth from the GBS bacteria that can often live harmlessly in the mothers vagina. ***Neisseria meningitidis*** is a ***gram negative diploccous*** bacteria. Meningococcal septicaemia is the cause of the classic “***non-blanching rash***” that everybody worries about as it indicates the infection has caused ***disseminated intravascular coagulopathy*** (***DIC***) and ***subcutaneous haemorrhages***. ***Meningococcal meningitis*** is when the bacteria is infecting the ***meninges*** and the ***cerebrospinal fluid*** around the brain and spinal cord.

Answer 25

fever, neck stiffness, vomiting, headache, photophobia, abnormal skin colour, altered consciousness, shock: prolonged CRT, hypotension, DIC, and, seizures. Where there is ***meningococcal septicaemia*** - ***non-blanching rash***. Other causes of bacterial meningitis do not usually cause the non-blanching rash.

Answer 26

Neonates and babies can present with very ***non-specific*** signs and symptoms such as hypotonia, poor feeding, lethargy, hypothermia and a ***bulging fontanelle***. For this reason NICE recommend ***lumbar puncture*** as part of the investigations for all children: * Under 1 months presenting with fever * 1 – 3 months with fever and are unwell * Under 1 years with unexplained fever and other features of serious illness

Answer 27

***Kernig’s test*** involves lying the patient on their back, flexing one hip and knee to 90 degrees and then slowly straightening the knee whilst keeping the hip flexed at 90 degrees. This creates a slight stretch in the meninges and where there is meningitis will produce spinal pain or resistance to this movement. ***Brudzinski’s test*** involves lying the patient flat on their back and gently using your hands to lift their head and neck off the bed and flex their chin to their chest. A positive test is when this causes the patient to involuntarily flex their hips and knees.

Answer 28

it is a medical emergency. ix and tx proceed in parallel ABCDE pts seen in community with suspected meningitis AND a non blanching rash should receive an urgent stat injection (IM or IV) of ***benzylpenicillin*** prior to transfer to hospital as time is so important. This shouldn’t delay transfer. Where there is a true penicillin allergy transfer should be the priority rather than other antibiotics. in hospital - ABCDE , fluid resus and IVI if req. check and correct blood glucose. ideally blood culture and LP for CSF culture and sensitivities before starting abx however abx shd not be delayed esp if septicaemic Send blood tests for ***meningococcal PCR*** if meningococcal disease is suspected. (faster than BC) low threshold for tx. Always follow the local guidelines however typical antibiotics are: * **\< 3 months and \>60 yrs or immunocomp**– ***cefotaxime*** plus ***amoxicillin*** (the amoxicillin is to cover listeria contracted during pregnancy from the mother) * **\> 3 months** – ***ceftriaxone*** ***Vancomycin*** should be added to these if there is a risk of penicillin resistant pneumococcal infection such as from recent foreign travel or prolonged antibiotic exposure. GET ICU help if signs of raised ICP (reduced GCS, papilloedema, seizures, focal neurology) or septicaemic (shock, evolving rash) Dexamethasone if features of meningism are also used in bacterial meningitis to reduce the frequency and severity of hearing loss and neurological damage. Bacteria meningitis and meningococcal infection are ***notifiable diseases*** so ***public health*** need to be informed of all cases. basically - ABCDE airway and breathing support if required get IV access take blood cultures fluid resus if req start IV abx +/- call ITU +/- dex LP when stable and raised ICP ruled out

Answer 29

The risk of highest for people that have had close prolonged contact within the **7 days** prior to the onset of the illness. Post exposure prophylaxis is guided by ***public health***. The usual antibiotic choice for this is a **single dose** of PO ***ciprofloxacin***. It should be given as soon as possible and ideally within 24 hours of the initial diagnosis.

Answer 30

***herpes simplex virus*** (***HSV***), ***enterovirus*** and ***varicella zoster virus*** (***VZV***). A sample of the CSF from the lumbar puncture should be sent for ***viral PCR*** testing. Viral meningitis tends to be milder than bacterial and often only requires supportive treatment. ***Aciclovir*** can be used to treat suspected or confirmed ***HSV meningitis***.

Answer 31

The spinal cord ends at the L1-L2 vertebral level so the needle is usually inserted into the L3-L4 intervertebral space. Samples are sent for bacterial culture, viral PCR, cell count, protein and glucose. A blood glucose sample should be sent at the same time so that it can be compared to the CSF sample. The samples need to be sent immediately.

Answer 32

***It makes sense that bacteria swimming in the CSF will release proteins and use up the glucose. Viruses don’t use glucose but may release a small amount of protein. The immune system releases neutrophils in response to bacteria and lymphocytes in response to viruses.***

Answer 33

* ***Hearing loss*** is a key complication * Seizures and epilepsy * Cognitive impairment and learning disability * Memory loss * Focal neurological deficits such as limb weakness or spasticity

Answer 34

CMV, cryptococcus and TB

Answer 35

odd behaviour, reduced consciousness, focal neurology or seizure preceeded by an infectious prodrome (raised temp, rash, lymphadenopathy, cold sores, conjunctivitis, meningeal signs). often wise to treat before exact cause is known as it is usually viral. if no infectious prodrome consider encephalopathy: hypoglycaemia, hepatic encephalopathy, DKA, drugs, hypoxic brain injury, uraemia, SLE, wernicke's (give vit B1 if in doubt)

Answer 36

viral: HSV 1&2, arboviruses, CMV, EBZ, VZV, HIV, measels, mumps, rabies non-viral: bacterial meningitis, TB, malaria, lyme disease, listeria, legionella, cryptococcus, leptospirosis, autoimmune

Answer 37

blood cultures, serum for viral PCR, throat swab and MSU, toxoplasma IgM titre, malaria film contrast enhanced CT: focal bilateral temporal lobe involvement is suggestive of HSV encephalitis. do before LP. LP - CSF protein, cells, glucose and viral PCR EEG- urgent EEG can confirm encephalitis but doesnt indicate cause

Answer 38

untreated encephalitis mortality - 70% start IV aciclovir within 30 mins of pt arriving as empirical treatment for HSV. specific therapies for CMV and toxoplasmosis supportive therapy in ICU/HDU environment if necessary symptomatic tx: eg phenytoin for seizures

Answer 39

in any pt with raised ICP, esp if fever or rasied WCC there may be hx of ear, ssinus, dental, periodontal infection, skull fracture, endocarditis, congenital heart disease, bronchiectasis signs: seizures, fevers, localising signs, signs of raised ICP, coma, signs of sepsis/infection ix - CT/MRI (ring enhancing lesion), raised WCC, raised ESR, biopsy Mx - ABCDE, urgent neurosurgical referral, treat raised ICP. is patient immunocompromised?? discuss with ID/microbiology

Answer 40

that there may be an anaeurysm in the posterior communicating artery or an intracerebral haematoma pressing on the IIIrd nerve

Answer 41

rebleeding cerebral ischaemia due to vasospasm hydrocephalus due to blockage of arachnoid granulations hyponatraemia (seek expert help. shd NOT be managed with fluid restriction)

Answer 42

They vary from benign tumours (e.g. ***meningiomas***) to highly malignant (e.g. ***glioblastomas***). **1.Secondary Metastases** The common cancers that metastasise to the brain are: * Lung * Breast * Renal cell carcinoma * Melanoma **2.Gliomas** Gliomas are tumours of the ***glial cells*** in the brain or spinal cord. There are three types to remember (listed from most to least malignant): * Astrocytoma (***glioblastoma multiforme*** is the most common) * Oligodendroglioma * Ependymoma Gliomas are graded from 1-4. Grade 1 are most benign (possibly curable with surgery). Grade 4 are the most malignant (glioblastomas). **3.Meningiomas** Meningiomas are tumours growing from the cells of the ***meninges*** in the brain and spinal cord. They are usually benign, however they take up space and this mass effect can lead to raised intracranial pressure and neurological symptoms. **4.Pituitary Tumours** Pituitary tumours tend to be benign. If they grow large enough they can press on the ***optic chiasm*** causing a specific visual field defect called a ***bitemporal hemianopia***. They have the potential to cause ***hormone deficiencies*** (***hypopituitarism***) or to release ***excessive hormones*** leading to: * Acromegaly * Hyperprolactinaemia * Cushing’s disease * Thyrotoxicosis **5.Acoustic Neuroma (AKA Vestibular Schwannoma)** Acoustic neuromas are tumours of the ***Schwann cells*** surrounding the ***auditory nerve*** that innervates the inner ear. They occur around the “***cerebellopontine angle***” and are sometimes referred to as ***cerebellopontine angle tumours***. They are slow-growing but eventually grow large enough to produce symptoms and become dangerous. Acoustic neuromas are usually unilateral. Bilateral acoustic neuromas are associated with ***neurofibromatosis type 2***. Classic symptoms of an ***acoustic neuroma*** are: * Hearing loss * Tinnitus * Balance problems They can also be associated with a facial nerve palsy. **6. primary CNS lymphoma (non infectious manifestation of HIV)** **7. cerebellar tumours**

Answer 43

asymptomatic (esp when they are small) As they develop they present with ***focal neurological symptoms*** depending on the location of the lesion. (eg personality change in frontal lobe tumours) symptoms and signs of ***raised intracranial pressure***

Answer 44

***Papilloedema*** is a key finding on ***fundoscopy*** Altered mental state Visual field defects Seizures (particularly focal) Unilateral ptosis Third and sixth nerve palsies ***headache -*** Constant Nocturnal Worse on waking Worse on coughing, straining or bending forward Vomiting

Answer 45

* Blurring of the optic disc margin * Elevated optic disc (look for the way the retinal vessels flow across the disc to see the elevation) * Loss of venous pulsation * Engorged retinal veins * Haemorrhages around optic disc * Paton’s lines which are creases in the retina around the optic disc

Answer 46

Management options include: * Palliative care * Chemotherapy * Radiotherapy * Surgery Surgery is dependent on the grade, location and behaviour of the brain tumour. **Treatment of Pituitary Tumours** * Trans-sphenoidal surgery * Radiotherapy * ***Bromocriptine*** to block ***prolactin-secreting*** tumours * Somatostatin analogues (e.g. ***ocreotide***) to block ***growth hormone-secreting*** tumours

Answer 47

present - headache raised ICP and NO intracranial mass found also narrowed visual firelds, blurred vision +/- diplopia, VIth nerve palsy, enlarged blind spot. consciousness and cognition preserved most commonly obese females associated with endocrine abnormalities, CKD, drugs (steroids, oral contraceptives, etc), SLE Ix - CT Head to rule out SOL Mx - wt loss, acetazolamide or topiramate, loop diuretics, prednisolone. consider optic nerve sheath fenestration or lumbar-peritoneal shunt if drugs fail and visual loss worsens often self-limiting but permanent significant visual loss in 10%

Answer 48

pain arising as a direct consequence of a lesion or disease affecting the somatosensory system

Answer 49

Peripheral * ***Postherpetic neuralgia*** from ***shingles*** is in the distribution of a ***dermatome*** and usually on the trunk * Nerve damage, including postoperative. * Diabetic neuralgia typically affects the feet * Trigeminal neuralgia * Pain because of cancer tumour infiltration. * Alcohol neuropathy Central * Multiple sclerosis * Post-stroke pain. * chemo induced pain not sure where this fits - ***Complex Regional Pain Syndrome*** (***CRPS***)

Answer 50

* Burning * Tingling * Pins and needles * Electric shocks * Loss of sensation to touch of the affected area * The pain may be provoked by normally innocuous stimuli (allodynia). Neuropathic pain is also commonly associated with hyperalgesia (increased pain intensity evoked by normally painful stimuli), paraesthesia and dysaesthesia.

Answer 51

**DN4 Questionnaire** They are then scored out of 10 for their pain. A score of 4 or more indicates neuropathic pain.

Answer 52

treatment of underlying cause Non-pharmacological measures: * Physiotherapy to maintain strength * Psychological input to help with understanding and coping * NICE recommends the use of spinal cord stimulation in patients who have had chronic pain for six months (measuring at least 50 mm on a 0-100 mm visual analogue scale) despite conventional medical management medications used - * Offer a choice of - * ***Amitriptyline*** is a tricyclic antidepressant * ***Gabapentin*** is an anticonvulsant * ***Pregabalin*** is an anticonvulsant * ***Duloxetine*** is an SNRI antidepressant **Other options:** * Tramadol ONLY as a rescue for short term control of flares * Capsaicin cream (chilli pepper cream) for localised areas of pain who wish to avoid, or who cannot tolerate, oral treatments. ***Trigeminal neuralgia*** is a type of neuropathic pain however NICE recommend ***carbamazepine*** as first-line for trigeminal neuralgia and if that does not work to refer to a specialist.

Answer 53

This is a condition where areas are affected by abnormal nerve functioning causing neuropathic pain and abnormal sensations. It is usually isolated to one limb. Often it is triggered by an injury to the area. The area can become very painful and hypersensitive even to simple inputs such as wearing clothing. It can also intermittently swell, change colour, change temperature, flush with blood and have abnormal sweating and hair growth. Treatment is often guided by a pain specialist and is similar to other neuropathic pain.

Answer 54

Radiculopathy is a neurological state in which conduction is limited or blocked along a spinal nerve or its roots. Radicular pain is usually caused by compression of the nerve root due to disc herniation or degenerative spondylotic changes, but radicular symptoms can also occur without evident compression (for example, due to inflammation of the nerve). they commonly occur together. Cervical radiculopathy is the term used to describe the pain in one or both of the upper extremities which corresponds to the dermatome of the involved cervical nerve root.

Answer 55

degenerative changes, including osteoarthritis, cervical disc herniation (22 per cent of cases), spondylosisand trauma

Answer 56

Pain in the neck, shoulder and/or arm that approximates to that of a dermatome. Sensory symptoms Motor symptoms Postural asymmetry. if the asymmetry is long-standing, muscle wasting may be present. Neck movements — these may be restricted or painful Dural irritation — assess with the Spurling test. Neurological problems — for example, upper limb weakness, paraesthesia, dermatomal sensory or motor deficit, or diminished tendon reflexes at the appropriate level. Nerve root symptoms should normally arise from a single nerve root — involvement of more than one nerve root suggests a more widespread neurological disorder.

Answer 57

The most common nerve root affected is C7, followed by C6.

Answer 58

Fever. Generalised neck stiffness. Lymphadenopathy. Nausea or vomiting. Pain that is increasing, is unremitting, or disturbs sleep. Severe neck tenderness. Skin erythema, wounds or exudate. Unexplained weight loss. Neurological problems like altered mental status, UMN signs A history of inflammatory arthritis, cancer, tuberculosis, immunosuppression, drug abuse, AIDS, or other infections. New symptoms before the age of 20 years or after the age of 55 years.

Answer 59

Thoracic outlet syndrome Acute disc prolapse Acute torticollis Acute trauma Adverse drug reactions (for example, antipsychotic drugs, metoclopramide, amphetamines, cocaine). Arthritis of cervical spine.

Answer 60

**If cervical radiculopathy has been present for less than 4–6 weeks and there are no objective neurological signs, provide conservative management:** Provide reassurance and information Encourage activity (including home exercise) and a return to a normal lifestyle (including work) as soon as possible. Offer oral analgesics advise firm pillow may help consider amitriptyline, duloxetine, pregabalin or gabapentin; physiotherapy; muscle relaxants **If cervical radiculopathy has been present for 4–6 weeks or more,** ***or*** **there are objective neurological signs:** magnetic resonance imaging (MRI) to confirm diagnosis consider invasive procedures, such as interlaminar cervical epidural injections, transforaminal injections, or spinal surgery. Indications for surgery include signs and symptoms of cervical radiculopathy with unremitting radicular pain despite 6 to 12 weeks of conservative treatments, or progressive motor weakness, and MRI that shows nerve root compression.