Week 3 Flashcards
When would you do a low neuro exam?
For patients with neck pain and (5)
- no radiating P into extremity or head
- no numbness, tingling, weakness in arms or legs
- no HA or CN sx
- no recent sig trauma
- patient under 50 yo
What are the Pathoanatomical ddx for Acute Traumatic Neck pain? (5)
Sprain Strain Facet syndrome Disc derangement Fracture
What are the Pathoanatomical ddx for NON-Traumatic Neck pain? (4)
Facet syndrome *1/3-2/3 of pts with persistent (chronic) neck pain
Disc derangement
Sprain
Strain
What percent of chronic neck pain patients have facet syndrome?
36 - 67%
Aka 1/3-2/3
What is the natural history/prognosis for patients with neck and arm sx?
80-90% will resolve w/in 8 weeks
40% will relapse w/in 1 year
What are the 5 main clues for nerve root lesion
Arm Pain (3 things: Quality *sharp, electrical, burning, stabbing; Location: known dermatomal; Arm > neck P) Arm Paresthesia SMR deficits Big 5 cervical ortho tests Spinal loading procedures
What are the “big 5” cervical ortho tests?
Cervical compression Cervical distraction Shoulder ABD Valsalva ULTT - median nerve
A list for radicular pain syndromes in the neck
A list for cord compression
NR:
1 - Osteophyte
2 - Disc herniation
3 - Stenosis
Cord:
1 - Disc hern
2 - Stenosis
B list for radicular pain syndromes in the neck
B list for cord compression
NR: 1 - Structural instab 2 - Tumor/SOL 3 - Infection 4 - NR adhesion 5 - Trauma to NR
Cord: 1 - Tumors/SOL 2 - Structural instab 3 - Cord trauma 4 - Fx/dislocation 5 - Cord adhesions 6 - Infection
What MOI can cause Trauma to NR directly?
Compression Hyperextension Lateral flexion with shoulder depression Hyperflexion Arm traction * brachial plexus only
C list for radicular pain syndromes in the neck
Disc derangement
Facet syndrome
Joint dysfunction
What is the 1st thing you do with a patient?
What is the 2nd thing?
3rd thing?
Disease or injury?
Is there nerve damage? (with the 5 things list)
Find the pathoanatomical dx (use the A, B, C lists), then biomechanical dx, and complicators or contributors
Indications for radiographs? (4)
1 - Trauma
2 - Red flags
3 - Neuro Sx (cord/radicular)
4 - Nonresponsive >1 month failed conservative care
HIGHEST Indications for cervical MRI in disc cases after radiographs have been taken?
1 - Myelopathy
2 - Progressive MOTOR deficit
3 - Non-responsive to conservative care
4 - Presurgical exam
What blood tests in blood chem panel may point to bone cancer?
Alk phos = bone building disease
Ca2+ levels = bone breakdown disease
Proteins = MM
How does syringomyelia present?
Diffuse “cape-like” distribution of pain/temp loss over 1 or 2 shoulders
What cervical conditions do oral corticosteroids put the patient at risk for? (2)
Osteoporosis
Ligamentous instability especially the upper cervicals
How do you perform arm squeeze test? How do you interpret it?
When there is NR compression, 1+ nerves of the arm are sensitive to moderate compression of the biceps and triceps area and should be more painful than other areas of the shoulder and upper arm.
Positive test hurts 3+ more or during the pressure on the middle 1/3 of the upper arm, compared with compressing the AC and anterolateral-subacromial areas.
E.g. if the shoulder hurt 1/10 but arm hurt 4/10 that suggests it may not be a shoulder problem but a nerve problem from the neck.
Atypical presentations of cardiac distress are usually found in people who are (3)
- Older patients
- Non smokers
- no previous Hx of angina
If you take your hands away form the neck when performing Kemps, what do you chart that as?
Quadrant test
What is the clinical decision rule for facet syndrome?
What is the +LR?
- positive ER test
- P with static palp over facet
- restriction to PA joint glide
+LR 4.95
What 2 types of clues to focus on when you think there are nerve root problems?
1 - Deficits and
2 - Paresthesia distribution (NOT pain) is more predictive than pain distribution
What are the 3 top indicators of a C8 radiculopathy in order?
- Sensory loss in the little finger
- Diminished triceps reflex
- Weak finger flexion
Which of the 5 big cervical ortho tests are sensitive?
ULTT—median n. is sensitive
The other 4 are not.
What does it mean when e.g. valsalva is not sensitive?
If valsalva is negative, it isn’t very useful.
Useful when it’s positive, not useful as an individual test when it is negative
Age range for cervical disc herniation?
40-60
Peak age 50-54
Rare <30 but not impossible
What pattern of physical exam procedures and their findings would suggest a nerve root that was most susceptible to compressive forces? (4)
AROM: extension, ips-rotation/lateral flexion
AROM: flexion, contra-rotation/lateral flexion
Cervical compression
Cervical distraction
What pattern of PE procedures and their findings would suggest a nerve root that is more sensitive to tension forces? (2)
ULTTs
Shoulder abd test/ Bakody’s sign
What are the key indicators to order a cervical radiographic series?
- Moderate to high load trauma
- Red flag for disease
- Cord/Radicular sign/sx
- Non responsive cases
What are the HIGHEST indicators for when to order an MRI in a patient with a cervical disc herniation? (AKA standard of care)
◦ suspicion of myelopathy
◦ progressive deficit
◦ non responsive to conservative care
◦ pre-surgical exam
What is standard of care?
When you practice and do what any reasonable doctor would do
What is medical necessity?
You have enough evidence to justify a particular Tx or study
You need to prove that the study is a reasonable step
What are things to do in office for disc herniation?
McKenzie evaluation - can try for acute pt
Neuromobilization - NOT acute pt: wait a few weeks
Manipulation
What does a manipulation schedule look like for a cervical disc herniation patient?
Manipulation 3-5x/week for 2-4 weeks then 1-3x/week
What is the prognosis for cervical disc herniation patient?
50% better in 2-4 weeks
70% better in 1 month
86% better in 3 months
If your patient has pain or paresthesia along the Medial side of the hand (little finger), where in the nervous system might the lesion be?
- Lower brachial plexus injury e.g. TOS, tumor, stretch trauma “plexitis or plexopathy”
- Ulnar nerve entrapment or nerve root “neuritis or neuropathy”
- MFTPs
- Nerve root “radiculitis or radiculopathy”
What specific muscles with MFTPs might project pain into the medial hand (little finger)?
- Latissimus dorsi
- Serratus anterior
- Pectoralis Major or Minor
