Week 2 Reading Flashcards
What is the evaluation strategy laid out in the CSPE for neck pain and arm symptoms?
1 - Rule out fractures and nonmechincal causes (disease)
2 - check neuro involvement
3 - Identify pain generator or cause of neuro damage
4 - Pain generating biomechanical/functional lesions
5 - Identify any pain relieving postures
6 - phase of injury
7 - check severity of the condition
8 - determine need for imaging or other neurophysiological lesions
9 - identify local complicating factors
10 - identify psychosocial issues or other chronicity
11 - Identify contributing or sustaining factors
12 - Set outcome measures
13 - establish a prognosis
Evaluation strategy acronym
Fat Nerds Generate Big Red Panda Services, Imagining Computer Social Cats Out Partying
Red flags for suspected fractures
Radiographs indicated
High impact injury
Head/neck trauma due to fall
Older than 50 with moderate or low impact injury
Cervical trauma in patients with impaired mentation
Patients with special risks (another card)
Headache or trauma with focal neurological deficits
Significant spasm or tenderness after trauma
What are some things that patients with special risk of fracture may have?
Fused spinal segments Down's syndrome Marfan's syndrome Os odontoideum Klippel-Feil syndromes Underlying inflammatory diseases such as RA
Indicators for fracture (not red flags)
Sharp, severe, intolerable pain
Rust’s sign - fracture instability, severe sprain
Significant neck flexor weakness, post traumatic - fracture or structural instability
Red flags for disease from history
Prior history of cancer Unexplained weight loss Unvarying symptoms Diffuse cape-like distribution of pain/temperature loss Horner's syndrome Fever/chills Recent bacterial infection Palpable mass Pain unimproved with a month of treatment Neck pain with urinary retention/incontinence Multiple joint involvement Currently taking anti-coagulants
Peak incidence of radicular syndromes is what age?
50-54 yo
What three clues provide strong suspicion of radicular syndrome
Pain radiating into the forearm or hand
Paresthesia to the fingers
Neurological symptoms
What five clues provide a weaker suspicion of radicular suspicion
Pain radiating past the GH joint but not past the elbow
Moderate to severe trauma to the neck
Neck and leg symptoms
Suspected diagnosis which has the potential to affect nerve roots
The two leading causes of cervical radicular syndromes
Herniated discs
Osteophytic spurs
Onset of neck pain and additional symptoms in cervical radiculopathy
Other symptoms appear after an average of 18 days
Classic characteristics of arm pain in nerve root pain
Lancinating or shooting quality
Radiating into the extremity in a narrow band less than two inches wide
Often exceeds the intensity of the neck pain
Dermatomal
Aggravated by minor movements, coughing or sneezing
Symptom behavior of nerve root symptoms (history)
Sx may be unrelenting for 24 hours
Pain can seem to be worse at night
Patient’s symptoms that change with PE
responsive to treatment or activities that open or close the IVF
Or increase or decrease the tension on NR
Both or one
No apparent pattern
Red flags from Ancillary Studies
Elevated ESR or CRP
Anemia
Strong suspicion of radicular syndrome
Pain radiating into the forearm or hand
Paresthesia to the fingers
Neurological symptoms
Weaker suspicion of radicular syndrome
Interscapular pain
Pain radiating past the GH joint but not past the elbow
Neck and leg symptoms
Suspected diagnosis which has the potential to affect nerve roots
Two leading causes of cervical radicular syndromes
Herniated discs and osteophytic spurs
Typical symptoms of cervical radiculopathy
Unilateral neck pain (MC)
Radiating arm pain (MC)
Finger paresthesia
occasional neurological complaints
Time interval between the onset of neck pain and the other symptoms
averaged 18 days in one study
Classic characteristics of arm pain in radiculopathy
Lancinating or shooting quality
Radiating into the extremity in a narrow band less than two inches wide
Often exceeds the intensity of neck pain
Dermatomal and easily aggravated by minor movements, coughing, sneezing
Three qualities of paresthesia in radiculopathy
Radicular symptoms are characterized by proximal pain and distal paresthesia in the distribution of the affected nerve root
Paresthesia may fit more commonly into known dermatomal patterns
Numbness in the extremities may develop with minimal or no pain
Acute nerve root symptoms may be __ ___ _ ___ and pain can seem ___ __ ___
24 hours a day; worse at night
Radicular syndrome symptoms respond to what three things
May be responsive to procedures or activities that open and/or close the IVF
May respond to increased or decreased tension on the nerve root
May demonstrate no apparent pattern at all
3 key physical presentation of radicular syndrome
Observation of painful postures and ROM
Orthopedic tests that aggravate or alleviate the extremity symptoms
ID any neurological deficits
Diagnostic cluster for radicular syndrome
Symptoms reproduced with one version of spurling’s test
Symptom reduction with cervical distraction
Symptom reproduction with an upper limb tension test
Cervical rotation reduced to less than 60 degrees toward the side of pain
Preliminary Obcervation and Range of Motion
Rust’s sign
Bakody’s sign - cervical disc herniation
Pain relief by putting palm to chest
Reduced rotation
Reproduction of symptoms with cervical compression and lateral flexion means ___ _ ___ NR is irritated and pathologically compressed
C6-C8
reduction of pain with shoulder abduction was ___ ___ ___ ___ and a negative test was ___ ___
Useful to rule in; not useful
Three positive results for ULTT
Symptom reproduction
>10% reduction of elbow extension compared to normal side
Symptoms aggravated by contralateral flexion and relieved by ipsilateral flexion
Likelihoods of DTR
Abnormal DTR in UE increases LR by 2.5
Abnormal biceps reflex is 10 times more likely to have root involvement
Which are more predictive deficits or pain distribution?
Deficits
Which cervical nerve roots are most affected?
C6 or C7
Clues for C5 radiculopathy
Pain in suprascapular region
Deltoid is weaker than biceps
Clues for C6 radiculopathy
Anterior or posterior deltoid, posterolateral arm or dorsal radial forearm
Pain in suprascapular region with lateral aspect of arm and forearm
Sx in multiple fingers
Clues for C7 radiculopathy
Pain in the scapular or interscapular region suggests a C7 or C8 root lesion
Pain in posterior deltoid, posterolateral arm or dorsal radial hand
Depressed triceps reflex (strongest clue)
Three symptoms of spondylolotic radiculopathy
Root pain is proximal, rarely extending below the elbow
Sensory symptoms are more common than motor
Paresthesia are often in the distal territories of the affected roots
Three signs of spondylolotic radiculopathy
Hyporeflexia
Atrophy
Progressive weakness including loss of grip strength
Joints to be evaluated for lesions along the kinetic chain
First and second rib AC and SC joint GH joint Elbow joint Carpal bones, distal radial
Differential diagnoses for a radicular syndrome
Disc herniation Spondylotic compression Stenosis Traction injuries Root adhesions/fibrosis Tumors Fracture Instability Infection Chemical irritation or NR
Six clinical suspicions for Cx disc herniation
Neck pain and decreased Cx AROM Arm pain centralizes Bakody's sign or positive shoulder abduction test Positive valsalva maneuver Positive compression/distaction Decreased biceps reflex (No evidence of osteophytes or spurs)
Clinical tip for osteophytes
Older patients with absence of other diagnosis
Findings that lessen likelihood of osteophytes
Little evidence of degenrative changes on radiograph
Arm pain centralizes with repetitive or sustained neck position
Bakody’s sign
Positive valsalva
___ __ ___ nerve roots are the most commonly affected NR
C6 or C7
C2 Nerve Root radiation
Pain at craniocervical junction with radiation to the posterior aspect of the head may suggest C2 radiculopathy
C3-4 NR radiation
Discomfort about the posterior neck, occiput, and over the trapezius muscle to the shoulder
C5 NR radiation and affected muscles
Pain in suprascapular region
Paresthesia to the fingers
Weak biceps/biceps reflex
C7 NR Most common findings
Decreased triceps reflex
Weak elbow extension
Sensory loss over middle finger
Posterior deltoid, posteriolateral arm, dorsal radial hand
C8 NR Most common findings
Sensory loss over little finger
Decreased triceps reflex
Weak finger flexors
scapular/interscapular/medial arm
C6 NR most common findings
Decreased biceps or brachioradialis reflex
Sensory loss over the thumb
Weak wrist extension
anterior/posterior deltoid, posterolateral arm, dorsal radial arm, suprascapular region
Symptoms of spondylolotic radiculopathy
Proximal root pain, rarely below the elbow
Distal paresthesia
Signs of spondylolotic radiculopathy
Hyporeflexia
Atrophy
Progressive muscle weakness and loss of grip strength
Theories for causes of Complex Regional Pain Syndrome
Hypersensitized central nervous system, sensitized peripheral receptors, a modified role for sympathetics
The five main types of symptoms associated with Complex Regional Pain Syndrome
Pain, autonomic dysfunction, edema, movement disorder and dystrophy
Features of pain in CRPS
severe, burning pain becoming regional with palmar and plantar dominance
Are spasms, increased reflexes and muscle weakness common in CRPS
Yes
4 common causes of somatic referred pain
Facet syndrome
Internal disc derangement
Subluxation syndrome
Myofascial pain syndromes
What is a common DDX from the spine that can closely mimic cervical radiculopathy?
Facet syndrome
In chronic pain from whiplash 40-68% of patients pain was from what?
Facet pain
MC C5-6;2-3
Palpatory findings for cervical facet syndromes (best evidence)
Tenderness over facets
Tissue changes over the facet
Joint restriction
Joint loading findings for cervical facet syndrome
Local pain with active or passive extension
Local pain with cervical compression
Local pain in the quadrant position or cervical kemps
Sources of pain in internal disc derangement
Pressure of discal material against the Posterior Longitudinal Ligament
Tears in the thicker anterior annulus
Clinical presentation of Internal Derangement
Neck pain with or without referred pain
Self-limited episodes in younger people with acute torticollis
Intermittent scapular pain
May be aggravated by cervical compression
Less likely to have localized tenderness over the facet
Somatic referred pain from internal derangement may be improved by what motions?
Chin retraction, neck extension, or another direction
Elderly patient with scleratogenous diffuse bilateral neck pain
Central disc bulge or herniation without myelopathy or radiculopathy
Irritated PLL or dura mater
Not very common
Key physical exam findings for subluxation syndromes/joint dysfunction
Reproduction of dorsal pain with head rotated to the symptomatic side
Sometimes a positive doorbell sign
Palpable joint dysfunction in the lower cervicals
Symptom relief with cervical manipulation
2 or more of the following criteria are required for joint dysfunction/subluxation syndromes
Altered motion by palpation (all-encompassing use)
Tenderness or dysesthesia elicited by static or motion palpation
Palpable spasm or change in tissue texture near joints
Reduction of tenderness with joint challenge
Palpable malposition
Under what circumstance may subluxation cause radicular pain
when present with anatomical changes such as stenosis or other degenerative changes causes ischemia to the NR
Arm symptoms associated with neck subluxations are likely associated with what?
Somatic referred phenomenon
How can myofascial pain syndromes can mimic a radicular syndrome?
Referred pain, numbness, or paresthesia
T/F a sensitive spot in a muscle identifies an MFTP
False
Taut band, palpable mass, recreation of familiar pain, Muscle has painful limitation to stretch
Essential criteria for MFTPs
Exquisite spot tenderness of a taut band or a nodule in a taut band
Pressure on the TP reproduces the patient’s pain AND patient recognizes the same pain that they complain of
Painful limitation to full stretch of the muscle
Confirmatory observations for MFTPs
Local twitch sign (low sensitivity and high specificity)
Referred pain or altered sensation in an area that the patient can identify as their Sx
Electromyelographic evidence of spontaneous activity in the area of MFTP
Pain/paresthesia in expected referral pattern but not familiar is a latent MFTP
Three evaluation steps for an identified myofascial pain syndrome
Assess other muscles in the same functional unit for dysfunction
Identify activities that may have to the development of the syndrome
identify any other structural or functional causes that result in the persistence of the TP (chest breathing, LLI, pelvic distortions, etc.)
Joints that should be evaluated in the case of multiple joint lesions along the kinetic chain
First and second rib Acrioclavicular joint and sternoclavicular joint Glenohumeral joint Elbow joint Carpal bones, distal radial-ulnar joint
T/F reproduction of the pain that the patient complains of when palpating a tender territory is indicative of multiple lesions in the kinetic chain
F
It is possible that this is hyperalgesia from NR irritation or central sensitization at the cord level
So possible but not a definitive clue. Direct therapy at the region in question to see if it alleviates symptoms
DDX list for radicular syndrome
Disc herniation Spondylotic compression Stenosis Traction injuries Root adhesions/fibrosis Tumors Fracture Instability Infection chemical irritation
The two most common causes of radicular pain syndrome are
Disc herniations
Spondylotic spurs and osteophytes
Clues that strengthen the suspicion of cervical disc herniation
Neck pain and decreased active cervical ROM
Arm pain centralizes with repetitive or sustained neck positions
Bakody’s sign or positive shoulder abduction test
Positive Valsalva maneuver
Positive cervical compression/distraction tests
Decreased biceps reflex
No evidence of osteophytes or significant spurring on radiograph
The first differentiation in older patients with radiculopathy
Spondylotic compression
Findings that cast doubt on spondylotic compression as a diagnosis
Little evidence of dengerative changes on the radiograph
Arm pain that centralizes with repetitive or sustained neck positioning - herniation
Bakody’s sign or positive shoulder abduction test - herniation
Positive Valsalva maneuver - herniation or tumor
What can cause direct trauma/traction to the NR
Whiplash injuries
Compressive force to the top of the head (esp. in ext.)
Traumatic shoulder depression with cervical side in c/l LF
Findings that suggest NR adhesion
Intermittent arm pain (if constant mb significant acute inflammation or other Dx)
Increased arm pain with cervical flexion that is brief and resolves rapidly when tension is released
Sx produced at end range of NR stretch
Patient present with deviation of the neck towards the affected side with flexion/extension
No significant improvement in ROM with repetition
significant instability is defined as
> 3-4 mm of movement on flexion-extension radiographs
Infections of the spine are associated with what ancillary finding
ESR over 50 mm/hr
Differential diagnosis for a myelopathic syndrome
Disc herniation Spinal stenosis Tumors (Structural) instability Neurapraxis injury Fracture Cord/meningeal adhesions/fibrosis Infection
The two most common causes of cervical cord compression
Cervical disc herniation and spinal canal stenosis
Significant cord compression is considered a contraindication to what?
Manipulative therapy
Diagnosis of disc herniation requires what ancillary test?
MRI, advanced imaging
Summary of effects of spinal stenosis
Motor deficits are more likely
Myelopathy is more likely
Post-traumatic symptoms are more likely
