History
The most common causes for radicular pain in cervical region (The "A" list).
what are :
-osteophytes
-disc herniations
-spinal stenosis
L'hermitte's sign will be positive in someone who has this condition.
What is a spinal cord myelopathy
Patient has +1 biceps reflex. Where could the neurogical lesion be ?
C5-C6 nerve root
musculocutaneous nerve
5 indications for radiographs in patients with neck or neck + arm pain
1) mod to high load trauma
2) Red flags for disease
3) cord signs/ symptoms (if yes ->do MRI)
4) radicular symptoms
5) non responsive cases (>1 mo)
History: Pt has a sense of numbness in his whole right hand that gets worse throughout the day. He notices that his fingers sometimes blanch very white when he enters a cold room. Also complains of general and lower neck and upper back ache.
tell me what tests you would do,
T4 syndrome
______ are more common in older patients (>50-60 yrs) with radicular symptoms where as ______ are more common in younger patients (<50-60 yrs)
1) osteophytic spurs
2) disc herniations
the two tests to check integrity of the posterior column of the spinal cord
what is vibration and proprioception?
Out of the big 5 ortho tests for radicular syndromes, only one of them is highly sensitive.
what is the ULTT-median nerve? (good @ ruling it out)
Conservative care options for the initial phase of care for disc herniations
Manipulation (thrust/ mobilizations)
traction/ flex-distraction
repetitive end-range loading (McKenzies)
Brief collar?
40 yr old barber has bouts of severe neck and arm pain for the last month. Pain radiates down the inside of right arm all the way to the hand.
C7 radiculopathy and myelopathy
breif morning stiffness (<1 hour), cervical crepitus and significant reduced rotation symmetrically even without being limited by pain and 3 common findings in a patient with this condition
what is a patient with osteophytes?
minimum requirements to make a “true” neurogenic TOS diagnosis
1)A reproducible neurological deficit seen in the physical exam
2) positive EMG-NCV study demonstrating plexus damage
5 ortho tests for TOS?
Adson’s test
hyperabduction test
costoclavicular test
Roos test
Tinnel’s test.
When ordering an MRI for a suspected disc herniation, there is a lowest level requirement, moderate level and highest level. What is needed to be in the moderate level ?
what are signs of motor deficits.
(lowest= Sx of radiculitis, highest = suspicion of myelopathy, progressive defcits, non-responsive care or presurgical care)
65 yr old patient has neck pain and left arm pain intermittently for the last six months. Neck pain is dull and achy, mostly on the left. Sharp pain will sometimes radiate down lateral arm past the elbow. Sometimes a "cold feeling" in thumb and first finger of left hand. History of three whiplash injuries over the last 10 years. All were treated and all resolved.
Osteophytes causing radiculopathy of C6.
Muscles with myofascial trigger points that mimic a C6 radicular syndrome.
scalenes, supraspinatus, subclavius
Patient presents with fatigue, heaviness in the extremity, nonpitting edema of hand or arm, cyanosis, ecchymosis, distended engorgement of superficial veins in the infra clavicular areas upper extremity and chest.
what are signs/ symptoms suggesting significant venous compression in a TOS case.
Reflex; Deep tendon (stretch reflexes) & Pathological
Muscle strength (proximal & distal). In hand-> hand intrinsics, rapid open and close, and finger escape sign
Sensory (posterior column and lateral spinothalamic)
prognosis for disc herniations
generally good: 40 % of herniations resorb
-get better within 2-3 months of conservative care (sometimes longer)
-study: suggested that 90% of ppl will improve with conservative care .
27 yr old. Whole neck is stiff (esp in the upper cercicals. Neck aches (3/10 VAS) punctuates with sharp pain in the posterior neck. No radiation, numbness, tingling or weakness in the arms. Started a few days ago and has been getting worse. Patient helped a friend wallpaper.
-end range ext causes neck pain. (-) cervical compression in neutral, rot + ext to the right hurts alot in right side of C4-C6 Sps. there is palpatory evidence as well as multiple segmental restrictions.
facet syndrome
remember you need three things: 1) +ER test 2) pain over facets with palpation has to be 3/10 3) P-A joint restrictions
Consequences of a lower trunk brachial plexus injury
Weakness of wrist/finger flexors, intrinsic muscles of the hand
Paralysis may lead to claw hand
C8-T1 sensory loss
Sympathetic changes (edema, tropic changes in forearm and hand)
Horner’s syndrome
4 abnormal reflexes that could be positive in someone who has a spinal cord myelopathy
what are:
1)hyperreflexia (+3/+4)
2)Paradoxical reflexes
3)clonus
4)pathological reflexes (babinski/ hoffman)
Positive findings in the physical that would cast doubt on osteophytic compression being the best diagnosis for a radicular syndrome? (4)
1) little evidence of degenerative changes on radiograph
2) Arm pain centralizes with repetitive or sustained neck position (AKA McKenzies)
3) Bakodys sign/ + shoulder abduction
4) + valsalva
Difference between relative radiographic stenosis vs absolute radiographic stenosis
10-12 mm relative radiographic stenosis (neuro damage?)
</= 10 mm absolute radiographic stenosis
** But any MRI is necessary to see if there really is neuro compromise.**
Patient has a C7 myelopathy. what are you going to find in your exam findings?
LMNL @ C7; S= loss of sensation middle finger, M= weak triceps, R=diminished triceps reflex.
UPML @ below C7