Neuro

Question 1

Systemic disease neck pain

Answer 1

Associated with polymyalgia rheumatica, RA, other inflammatory conditions
Other joint complaints and prolonged morning stiffness
Symmetric loss of ROM at cervical spine
Labs- CRP, ESR increased

Question 2

Myelopathy produced by cervical stenosis

Answer 2

Dose not always cause neck pain
Spastic gait disturbances, weakness in BLE, upper motor neuron signs like hyperreflexia, increased muscle tone, positive babinskis
Can also have lower motor neuron findings in upper extremities
Bladder symptoms like urgency, frequency, and retention

Question 3

Cervical radiculopathy

Answer 3

Pain in the neck and arms, sensory loss, loss of motor function, reflex changes in the affected nerve root distribution
Usually due to encroachment of the neuroforamina of the cervical spine the C7 root most commonly affected
Pain that is reported by rowing the head or bending toward symptomatic side
Improve with symptomatic TX only small number require surgery

Question 4

Nonspecific mechanical disease of cervical spine

Answer 4

Cervical disc replacement
Local muscle spasms that can be mistaken for trigger points of fibromyalgia
Asymmetrical loss of ROM of cervical spine and weakness of muscle innervated by cervical nerve roots like elbow extension and finger abduction in C7, C8, T1 disease
Limited data on therapy effectiveness exercise, manual therapy versus surgery but that should’ve saved for significant or persistent or worsening signs

Question 5

Back pain (tumor)

Answer 5

Persistent progressive pain at rest, systemic symptoms
No focal abnormalities may have other systemic symptoms
Anemia, increased ESR, abnormal bone scan or MRI

Question 6

Back pain (infectious)

Answer 6

Persistent pain with fever, at risk patients like indwelling catheter
Tender spine
Increase ESR, WBC, positive bone scan or MRI

Question 7

Back pain (unstable lumbar pain)

Answer 7

Recurring episodes of pain during changes of position
Pain going from flexed to extended position
MRI or CT showing one disk space narrowed or sclerotic spondylisthesis

Question 8

Back pain (lumbar spinal stenosis)

Answer 8

Pain on standing and walking and relieved by sitting and lying
Immobile spine, L4, L5, S1 weakness
MRI CT showing stenosis
Can also have sciatic pain and pain in calf (pseduoclaudication)
Surgery seems to have most benefits

Question 9

Sciatica

Answer 9

Pain in posterior aspect of leg may be incomplete
Often positive straight leg raise L4, L5, S1 weakness
Variable imaging findings

Question 10

Back pain (vertebral compression fracture)

Answer 10

Sudden onset of severe pain, resolves in 4-6 weeks, pain on any movement of spine, no neuro deficits.
Vertebral end plate collapsed, compression fracture seen on plain film
1/3 have symptoms
Analgesics
Reserve survey for non responders
TX for osteoporosis!!

Question 11

Back pain (osteoporotic sacral fracture)

Answer 11

Sudden lower back, buttock, or hip pain
Sacral tenderness
H shaped uptake on bone scan
Tx for osteoporosis!!

Question 12

Red flags that warrant imaging without delay

Answer 12

If discovery of vertebral compression fracture will change management
Neurological deficits
Bowel or bladder dysfunction
Fever
History of cancer
Imaging not needed for LBP alone in first six weeks unless red flags present

Question 13

Peripheral neuropathy

Answer 13

Can cause gait impairment from sensory and motor deficits
PE, can also do nerve conduction study or electronyography
Refer out for acute, atypical, rapidly progressing or severe forms
Multiple underlying causes
TX underlying cause
Can also use- TCA (off label), gaba, lyrics, cymbalta, tapentadol, opioids (off label), topical agents

Question 14

Radiculopathy

Answer 14

Compression of spinal root as it exits spinal cord
Can be from herniated disk or osteophyte formation
Pain radiates down neck, back, arm or leg
Motor and sensory deficits, diminution of reflexes in distribution of spinal roots
MRI with contrast and LP with cytology

Question 15

Acute inflammatory demyelinating polyradiculoneuropathy

Answer 15

AKA Guillian barre syndrome
Acute immune mediated form of polyradiculopathy
Chronic inflammatory demyelinating polyneuropathy is a form of AIDP that require long term immunotherapy
Patients with DM may present with diabetic amyotrophy a lumbosacral polyradiculitis and plexopathy that starts with subacute onset of severe neuropathic pain in the thighs that’s asymmetric, followed by proximal muscle weakness in legs and atrophy
Refer severe case

Question 16

Myopathy

Answer 16

Proximal muscle weakness, wasting, diminished or absent reflexes
Can be associated with increase in muscle enzymes, myopathic pattern on electromyogram, and abnormal muscle biopsy

Question 17

Polymyositis

Answer 17

Disorder of skeletal muscle
biopsy shows lymphocytic infiltration, and usually also myocyte degeneration and regeneration, TX with prednisone

Question 18

Thyroid related myopathy

Answer 18

Weakness and wasting greatest in the pelvic girdle muscles and may extend to the shoulder region
Reflexes can be normal and diagnosis is based on distribution of muscle weakness
Improves with success TX of underlying endocrine disorder like hypothyroid

Question 19

Drug induced myopathy

Answer 19

Drugs like steroids, statins, colchicine, procainamide

Question 20

Motor neuron disease

Answer 20

AKA amyotrophic lateral sclerosis (ALS)
Progressive fatal neuro degeneration condition involving upper and lower motor neuron cells
Progressive weakens and wasting of skeletal muscle in combo with bulbar palsy and respiratory failure
Gait disturbance, falls, foot drops, weakness in grip, dysphasia, dysarthria
Electromyography for DX shows diffuse denervation and poor recruitment of motor units
2-3 yr survival rate
Supportive TX, rifluzole, trach

Question 21

Myelopathy

Answer 21

Spinal cord dysfunction
Spinal cord tumors, vascular events, or trauma
Cervical spondylitis, disc prolapses or herniation, vertebral body subluxation due to RA, meningioma or spinal CA
MRI for DX but abnormal findings can be common in older adults
Surgery for persistent pain or progressive neuro symptoms

Question 22

SDH

Answer 22

Subdural hematoma
Blood between dura and arachnoid
Likely trauma related
HA, slight to severe cognitive impairment, seizures, hemiparesis, focal neurologic signs, imaging shows extra atrial blood collection
Removal of blood may be warranted if symptoms are worsening or clinical monitoring if no s/s

Question 23

MS

Answer 23

Recurrent occasionally progressive inflammatory demyelinating of white matter in brain and spinal cord
Varied neuro symptoms
Autoimmune
Unknown causes, HLA antigens, genetics?, herpes virus, latent infection, vitamin D deficiency
Unilateral vision loss, diplopia, hemiparesis, fatigue, mobility, cognitive dysfunction, bowel and bladder, depression and mood disorders
DX with MRI, LP
Neuro signs at least two separate areas of involvement two areas of CNS involved two different attacks
Types- relapsing remitting, secondary progressive, progressive relapsing, primary progressive
TX- symptom based, therapy, yoga, cannabis extracts?, CAM, steroids

Question 24

Guillian barre syndrome

Answer 24

Myelin sheath is attacked and destroyed cannot transit signal
Inability to feel pain or sensation
Weakness, facial droop, dysarthria, muscle paralysis, absent reflexes
Nerve conduction study, LP, PFT, MRI
TX- close observation in hospital, plasmaphoresis, immunoglobulins, steroids, therapy

Question 25

Myasthenia gravis

Answer 25

Auto antibodies attach acetylcholine receptors preventing muscle contraction Thymus starts it? Intermittent diplopia, ptosis, difficulty chewing and swallowing, specific muscle weakness, limb weakness, severity fluctuates during the day, less in AM progresses throughout day Classes-ocular alone, mild general: moderate to severe general, acute severe over weeks, late severe TX- steroids? Control symptoms, therapy, prevent complications-cholinergic crisis, myasthenia crisis, respiratory distress, aspiration, malnutrition, thymus ectomy; plasmaphoresis, IVIG, cholinesterase inhibitors- pyriodostigmine, neostigmine

Question 26

A 79-year-old woman comes to the office because she has pain mainly in her right buttocks. The pain is worse when she stands her walks. She has a limp. She has unable to bear weight on her right leg without significant pain. MRI six months ago, showed diffuse degenerative changes throughout the lumbar area with stenosis at L4, L5, L5-S1. The patient has been treated by a pain specialist with a series of joint injections without significant relief. What is the appropriate next step?

Answer 26

Passive examination of the right hip

Question 27

A 78-year-old man comes to the office because he has pain radiating from his buttocks to his right heel the pain suddenly began 10 days ago it bothers him in all positions, especially at night. It limits his walking in his ability to climb stairs. He does not recall similar pain in the past although he does have intermittent low back pain. Exam shows that raising the right leg to 40° reproduce the leg pain, mild weakness of the great toe right hip abductor and right hip hip extensor full range of motion on both hips with no pain. MRI shows stenosis at L4, L5, L5-S1 and moderate disc displacement into the right L4-L5 inner space. which of the following statements is true

Answer 27

Between 50% and 75% of patients report improvement of pattern of pain within four weeks

Question 28

A 63-year-old woman comes to the office because she has difficulty walking. She says her gait has changed over the last six months and now has to use a walker. She fell one month ago while walking on an uneven pavement. She states that her legs just feel weak and lousy. She has no pain in her lower extremities, history of diabetes, osteoarthritis, and coronary artery disease review of systems show she has increased urinary urgency, constipation, and difficulty opening jars and buttoning her blouse. Exam shows impairment of fine motor skills of the hand, bilateral hyperreflexia in both ankles and patella and positive Romberg test which of the following is most appropriate next evaluation.

Answer 28

Order MRI of cervical spine