Week 7: questions, in class notes, RAT Flashcards
Which lumbar ortho exams suggest lumbar disc?
- Bilateral active SLR
- Bragard or Bowstring confirms disc herniation if SLR was hard positive
- Kernig
- knees to chest (position bias disc vs facet)
- Farfan torsion (Lx facet/disc)
- Bechterew’s
- Deyerlie (confirms)
What lumbar ortho exams suggest facet?
- knees to chest (position bias disc vs facet)
- farfan torsion (Lx facet/disc)
- kemp’s
What lumbar ortho exam suggests SI?
- Active SLR, resistance ASLR
- Patrick FABERE - SI/hip
- modified LaGuerre (hip)
- Thigh thrust
- Thomas Gaenslen’s
- SI distraction
- SI compression
- Sacral thrust
What are 4 indications for cervical xrays?
1 - moderate to high trauma load if it fulfills Canadian annexus rules
2 - red flags for disease
3 - cord or radicular signs/Sx
4 - nonresponsive to conservative care
When would you MRI? What are the schools of thought?
1 - If there are signs of CES
2 - Progressive mm weakness with conservative care
3 - Profound mm weakness
4 - If patient wants surgical consult
5 - If patient doesn’t respond as expected
6 - If there is suspected upper lumbar disc herniation
Schools of thought:
1: whenever there are nerve problems, MRI
2: only MRI if disc herniation has deficits
3: nope, only MRI if there is cord damage e.g. severe motor loss
If Kemps creates LBP only, what might it be?
Think Facet. Could be anything else including deranged disc
If kemps creates leg pain think:
Encroachment of IVF e.g. spur, stenosis, disc herniation
What is classic stenosis signs?
P with walking
Define: Neuropathic pain
Umbrella term that includes lesion of the brain, spinal cord, NR, plexus, or peripheral nerves
Define radicular pain syndrome
A type of neuropathic syndrome specifically due to a nerve root lesion.
2 types:
- Radiculitis (an inflamed nerve root but no neurological deficits) or
- Radiculopathy (a nerve root damaged to the point it has neurological deficits).
Define brachial plexitis
a type of neuropathic pain caused by inflammation of the brachial plexus.
Define Brachial plexopathy
a type of neuropathic pain caused by damage to the plexus severe enough to cause neurological deficits.
Define neuritis
type of neuropathic pain caused by inflammation of a peripheral nerve (as opposed to a nerve root or plexus)
Define neuropathy
type of neuropathic pain caused by damage to a peripheral nerve (as opposed to a nerve root or plexus) severe enough to cause neurological deficits. The result of a disease or an entrapment.
At what age would you want to x-ray a patient with sudden onset of spontaneous LBP?
70
MC location for compression fix?
TL junction
4 scenarios when you should order MRI in suspected lumbar disc herniation
Signs of CES
Profound or progressive mm weakness
If patient wants surgical consult
If there is suspected upper lumbar disc herniation
What are 3 PE items from 5 point check list to detect neural damage in a patient with LB and leg pain?
SMR testing (aka nerve compression tests)
Nerve tension tests
Spinal loading procedures (e.g. AROM, kemp’s, knees to chest)
List 5 positive PE findings that would particularly support a cervical disc derangement dx
Deep referred arm pain may be improved by repetitive end range movements into chin retraction, extension or some other direction Palpatory tenderness midline Positive valsalva Relieved by cervical distraction Aggravated by cervical compression
What 2 traumatic mechanisms (besides hyperextension) could directly injure a cervical nerve root?
Lateral flexion injury: falling on the head and shoulder
Compression: landing on the head
Patient has neck pain and sharp pain along back of triceps and a “numb” feeling in 4th and 5th fingers. Neck AROM is severely limited in flexion due to neck pain. Cervical compression and valsalva create neck pain and the shoulder abduction test decrease finger numbness. SMRs are normal. Write a complete diagnosis.
Cervical disc herniation with C8 radiculitis to the medial hand
What are clues that support radicular syndrome? Patient has neck pain and sharp pain along back of triceps and a “numb” feeling in 4th and 5th fingers. Neck AROM is severely limited in flexion due to neck pain. Cervical compression and valsalva create neck pain and the shoulder abduction test decrease finger numbness. SMRs are normal.
Pain: arm pain and quality is sharp and distribution is along the back of triceps
Paresthesia: numb feeling in 4th and 5th fingers
Ortho: shoulder abduction reduces arm pain
SMRs: normal
Spinal loading: no postive tests for radicular syndrome
List all the clues that this is probably a herniated disc (as opposed to stenosis, spur, tumor) Patient has neck pain and sharp pain along back of triceps and a “numb” feeling in 4th and 5th fingers. Neck AROM is severely limited in flexion due to neck pain. Cervical compression and valsalva create neck pain and the shoulder abduction test decrease finger numbness. SMRs are normal.
Neck flexion aggravates the patient (r/o stenosis)
Cervical compression and valsalva created neck pain which suggests disc involvement
Shoulder abduction reduces arm pain which suggests nerve involvement (r/o disc derangement)
What are pathoanatomical lesions? memorize
Sprain Strain Facet syndrome Deranged disc Fracture
What are biomechanical lesions? memorize
Joint dysfunction or segmental dysfunction
Myofascial trigger point
Myospasm
What are key findings used to determine severity of a muscle tear in the extremities? Explain how they can be used to cite the grade of the tear.
Weakness: no/mild vs mod vs seve
P w/ passive ROM: none vs pain, vs P/no P
Defect: none vs small vs large
What would tests/Sx look like for grade 1 sTRAIN?
P with resistance
No defect
Minimal swelling, bruising
No P with PROM (except when passively stretched)
NO gross instab
NO P with isometric mm testing
No weakness (or little)
NO defect
What would tests/Sx look like for grade 2 sTRAIN?
P w/ resistance Mild-mod weakness Small defect Mod swelling, bruising P with passive stretching (otherwise PROM is P-free)
What would tests/Sx look like for grade 3 sTRAIN?
P/no P with resistance Mod-sev weakness Larger defect Rapid, extensive swelling and/or bruising MM balls up, retracts, loses contour
What are 2 major parameters to consider when assigning a degree of severity to a MSK case?
Amount of tissue damage
Affect on patient (ADL, PSFS, OPS)
When measuring the effect on a patient, what are 2 main methods that are used?
ADL
PSFS
OPS
What are some key exam procedures and their findings to assess the amount of tissue damage in the extremities?
ROM
End play
Observation (bruising, swelling, erythema, hemearthrosis)
Isometric mm testing
Why don’t these same methods listed in the Qs above work well in the spine (except, sometimes, the cervical spine)?
The spine is difficult to find end play
Tissue damage is often too deep to show signs on the skin
It’s difficult to isolate muscles in the spine
What are the key findings used to determine the severity of a ligament injury in the extremities?
PROM
Observation (swelling, ecchymosis)
Instability
Weight bearing pain
What would tests/Sx look like for 1st degree/mild sPrain?
P on stress at endrange
Local tenderness
Mild local swelling
Minimal P w/ weight bearing
NO P w/ isometric mm testing
NO gross instab
What would tests/Sx look like for 2nd degree/moderate sPrain?
P on stress of tissue before end range Generalized, marked tenderness, swelling Mild laxity Local bruising Mod ROM loss Mod-sev P w/ weight bearing
NO P w/ isometric mm testing (or mild P set phase)
What would tests/Sx look like for 3rd degree/severe sPrain?
Gross instab Variable response to isometric mm testing: NO P, P “set phase,” or sig weakness Generalized swelling Tissue disruption Min-sev P Hemearthrosis and extensive bruising Marked ROM loss Abnormal motion and/or P with mm contraction
What type of SMR neuro deficit is considered to be the worst?
Muscle weakness
NR damage is more severe if there is motor weakness present.
What is the key distinguishing feature between grade 2 and grade 3 whiplash?
Grade 2 - MSK signs
Grade 3 - neuro deficits
Describe the grades of whiplash using the Quebec system
Grade 0: no complaint, no findings Grade 1: neck complaint, no findings Grade 2: neck complaint, MSK signs Grade 3: neck complaint, neuro deficits Grade 4: neck complaint, fracture or dislocation
What are 1˚ findings to support lumbar joint dysfxn?
Pain with palpation in open packed position
ROM: segmental
Tissue, texture, tone alterations in paraspinals (loss of symmetry)
What are 2˚ findings to support lumbar joint dysfxn?
Palpable malposition
Repetitive loading
Alterations in sectional or global ROM
Observational alterations in paraspinal tissue symmetry
What are MEDICARE requirements for lumbar joint dysfxn?
At least 2 examination findings must be present:
1-must be either A or R of PART mnemonic
2-second could include any of the PART mnemonic
Does palpation for altered motion have acceptable inter- and intra-examiner reliability?
Inter-examiner (2+ examiners, 1 exam) is poor 0.17
Intra- (1 examiner, 2+ exams) is slightly better 0.35
Exclude Gillette’s test (SIJ) and intra- goes to 0.44
Does motion palp for pain/tenderness have acceptable reliability for inter- and intra-examiner reliability?
Inter- 0.53
Intra- 0.91
What kappa value has been suggested as minimally acceptable?
0-0.25 is poor
- 26-0.50 is fair
- 51-0.75 is mod-good
- 76-1.00 is good-excellent
For physical medicine a 0.40 is generally acceptable though this number is arbitrary.
How would you explain what that number is actually telling you?
Agreement between 2 diff examiners doing the same exam (inter) or multiple exams with the same examiner (intra) is 40% better than pure chance
What are some key pertinent negatives for lumbar joint dysfxn?
Signs of NR involvement signals a search for additional pathoanatomical Dx especially when serious NR compression signs are present
Red flags for serious disease
Where does lumbar joint dysfxn diagnosis fit into the 4-part diagnosis?
Biomechanical
How is nerve damage different from disc damage?
Nerve damage:
- P in extremity sharp, stabbing, dermatomal
- Paresthesia: numbness, tingling, etc in extremity
- SMR deficits
- (+) Orthos
- (+) Spinal loading
Disc derangement:
- P in back: deep, achy, poorly localized midline/bilateral, constant/intermittent
- SMRs (nerve compression tests) normal
- 1˚ complaint: sitting intolerance, may aggravate LBP rapidly
- Pain centralization of Sx! ONLY exam finding supported by clinical evidence based on 3 studies
- Dejerine’s triad / Valsalva (spinal loading?)
- usually flexion load sensitivity, but can be aggravated by rotation, side bending
- minor’s sign
What degree of sprain is unstable?
3rd degree
What would you do to judge the severity of a sprain?
Check to see if they have: P at endrange weight bearing tenderness instability P with isometric mm testing
