B11 Cervical Neuro Assessment Flashcards
(73 cards)
1
Q
What are the 5 main clues for NR lesions in the cervical spine?
A
- pain in arm
- paresthesia in arm
- SMR deficits in arm
- cervical orthopedic tests change arm symptoms
- AROM and loading c-spine reproduce arm symptoms
2
Q
What are the 4 main questions from the history about arm pain when radicular syndrome is suspected?
A
- location (sometimes dermatomal and past elbow, superficial)
- quality (sharp, stabbing)
- severity (arm>neck)
- affected by spinal position (aggravates)
3
Q
Describe the arm pain associated with radicular syndrome?
A
Classic presentation is often NOT seen. The pain is often diffuse and poorly localized, rarely dermatomal (53.9%)
4
Q
Describe the arm paresthesia associated with radicular syndrome.
A
- starts distal and spread proximal
- more dermatomal than pain
5
Q
How do you predict which NR is affected in cervical radiculopathy?
A
Deficits and paresthesia distribution is more predictive than pain distribution
6
Q
Where is the C5 pure patch?
A
Deltoid tubercle
7
Q
Where is the C6 pure patch?
A
Thumb web on dorsal aspect of thumb
8
Q
Where is the pure patch for C8?
A
Medial tip of 5th digit
9
Q
What is the +LR associated with the C6 pure patch?
A
8.5
10
Q
What is the +LR associated with the C8 pure patch?
A
41.8
11
Q
What is the pure patch for axillary nerve?
A
Deltoid tubercle
12
Q
What is the pure patch for radial nerve?
A
Thumb wed of dorsal aspect
13
Q
What is the pure patch for median nerve?
A
Lateral tip of index finger
14
Q
What is the pure patch for ulnar nerve?
A
Medial tip of 5th digit
15
Q
What motor testing is done for C5?
A
Shoulder abduction
16
Q
What motor testing is done for C6
A
Elbow flexion
Wrist extension
Pronation
17
Q
What motor testing is done for C7?
A
Elbow extension
Wrist flexion
Finger extension
Pronation
18
Q
What motor testing is done for C8?
A
Finger flexion
19
Q
What motor testing is done for T1?
A
Dorsal interossei finger abduction
Palmar interossei finger adduction
20
Q
Of the muscle tests available for C6 radiculopathies, which is most commonly weak?
A
Pronation
21
Q
Why is is important to muscle test pronation in patients with suspected radiculopathy?
A
- It is the most common weakness in C6 radics
- in some cases of C7 radiculopathy,it is the only muscle with weakness
22
Q
What is the DTR for C5?
A
Biceps reflex
23
Q
What is the DTR for C6?
A
Brachioradialis relfex
24
Q
What is the DTR for C7?
A
Triceps reflex
25
All all of the SMRs for C6, which has the highest positive LR and therefore is the more predictive of C6 radiculopathy?
Decrease in brachioradialis (or biceps) reflex (14.2)
26
All all of the SMRs for C7, which has the highest positive LR and therefore is the more predictive of C7 radiculopathy?
Decrease in triceps reflex (28.3)
27
All all of the SMRs for C8, which has the highest positive LR and therefore is the more predictive of C8 radiculopathy?
Sensory loss on medial aspect of little finger (41.2)
28
What is a prolonged contraction of a particular muscle or increased muscle tone that results in abnormal posturing or a muscle spasm. Often painful and debilitating
Dystonia
29
What is a rhythmic contraction of large muscle groups, often described as a rolling or writhing motion, sometimes can be smaller ticks as well. Usually not painful
Dyskinesia
30
What are the big 5 cervical orthopedic tests?
```
Cervical compression
Cervical distraction
Shoulder abduction
Upper limb tension tests (median n.)
Valsalva maneuver
```
31
What are the three versions of cervical compression that should be done in orthopedic testing?
Neutral
Lateral flexion
Maximum
32
A positive maximum compression (aka spurling’s test) is evidence for what two conditions?
Radicular lesion
Disc herniation in cervical spine
NOTE: negative test does not rule out disc
33
What is the + LR of cervical distraction improving arm symptoms?
4.4
34
Improvement in arm symptoms with shoulder abductions is evidence for what two conditions?
Radicular lesion
| Disc herniation
35
What is Bakody’s sign?
Patient presenting with arm held about head for symptom reduction
36
What does a positive median nerve tension test suggest?
Irritation in the NR but it is not specific. Could be irritated NR, brachial plexus or median n.
37
Aggravation of symptoms with Valsalva is evidence for what conditions?
Radicular lesion
Disc herniation
SOL
38
Of the 5 cervical orthopedic tests, which is the only one good at ruling out radicular lesion (i.e. high sensitivity)?
ULTT-median
39
What positions cause compression of the IVF?
Extension
Ipsilateral rotation
Ipsilateral lateral flexion
Therefore flexion, contralateral rotation and lateral flexion will increase the size of the IVF
40
Since Kemp’s and quadrant position can aggravate symptoms of facet syndrome and NR lesions, who can you distinguish between the two.
If symptoms are immediately aggravated, think NR lesion. If position must be held to elicit worsening of symptoms, think facet syndrome
41
If lateral bending of the cervical spine reproduces arm symptoms, what is your first and second DDX?
```
1st = brachial plexopathy
2nd = NR lesion
```
42
What is the doorbell sign?
Pressing on medial border of SCM toward NRs recreates pain
43
What is the classic doorbell positive and what does it indicate?
Recreating pain between the shoulder blades
Indicates cervical referred pain
44
What is the alternate doorbell positive and what does it indicate?
Recreation of arm symptoms
Indicates cervical nerve root pain
45
What cluster of tests, when 3/4 are positive have a 65% post-test probability and when 4/4 are positive have a post test probability of 90% for radiculopathy in the cervical spine?
ULLT - median nerve
Cervical rotation <60 to symptomatic side
Distraction
Modified Spurling (aka max cervical compression)
46
Describe the pain pattern of cervical radicular symptoms?
There is not always a distinct pattern:
- can be unrelenting
- may be worse at night
- may ease up for a few days and then return
- sometimes respond to opening or closing of the IVF
- sometimes respond to traction on and off the NR
47
Cervical radicular symptoms may get worse with what movement of the neck?
- compression
- extension
- ipsilateral rotation
- ipsilateral lateral flexion
48
Cervical radicular symptoms may get better with what movement of the neck?
- traction
- flexion
- contralateral rotation
- contralateral lateral flexion
49
What positions may reduce traction on a cervical nerve root?
- Bakody’s
- shoulder abduction
- cradling the arm or resting on abdomen
50
What are the three most common causes of radicular syndrome in the cervical spine?
- osteophytes
- disc herniations
- spinal stenosis
51
What are the 5 less common (B-list) causes of cervical radiculopathy?
- trauma
- structural instability
- tumor/SOL
- infection
- NR adhesions
52
What are the 3 unlikely causes (C-list) of cervical radiculopathy?
- disc derangement
- facet syndrome
- joint dysfunction
VERY unlikely especially if there are neuro deficits
53
Based on experimental trauma, what percentage of cord volume can be lost and still have normal neurological findings?
30%
54
IF a patient is determined to have a NR problem, what is the next step?
Make sure the cord is not also involved
The reverse is also true
55
What are the general patterns of myelopathy in the cervical spine?
- Motor and reflex changes more common than sensory
- analgesia (deficits) are more common than anesthesia (depressed)
- LMNL at level of compression
- UMNL below level of lesion
- arm findings can be unilateral
- leg findings typically bilateral
56
WHat is more commonly the presenting symptom in cervical myelopathy?
- Motor and reflex changes
| - NOT pain
57
What is commonly an early sign observed in patients with cervical myelopathy?
Gait disturbances
- stumbling
- clumsy
- Frequent falls
58
What systemic symptoms may be present in 2/3 of cervical myelopathy patient’s?
Bladder dysfunction
- frequency
- urgency
- incontinence
- retention
59
What is L’ermitte’s sign? What is it associated with?
An electric shock like sensation running through the back and limbs upon flexion of the neck. Associated with cervical cord lesion because flexion stretches dorsal column
60
What are three diseases that can cause cervical cord lesions?
- compression for SOL, etc.
- MS
- B12 deficiency
61
What motor signs will be observed in the hands with cervical cord lesion?
Little finger escape sign with fingers squeezed together and into extension
62
If a cervical cord diagnosis is suspected, what ancillary study is indicated?
MRI
63
What abnormal reflexes will be present with cervical cord lesion?
- Hyperrefelxia
- Paradoxical reflexes
- Clonus
- Pathological reflex (babinski, hoffman)
- may be present in all four extremities
64
What is Tromner sign?
- Flick middle finger up
| - Positive test is index and thumb approximation
65
What is Hoffman’s reflex?
- flick middle fingertip down
| - positive test is index and middle finger approximation
66
What is dynamic Hoffman’s and when would it be used?
- Patient flexes and extends neck while doctor flicks middle finger tip down.
- This can help tease out Hofmann’s reflex
- will be positive in extension but normal in flexion
67
What is a positive Babinski?
Big toe extends and toes fan
68
When vibration is tested with a tuning fork on the DIP of the middle finger and toe, how many seconds should it be able to be felt?
- 15 seconds or more is considered normal
| - under 10 is considered abnormal
69
How is proprioception tested?
- position sense by moving patient’s joints with their eyes closed and seeing if they can indicate the direction
70
What is the most common cause of cord compression in patients under 50?
Herniation, midline
71
What is the most common cause of herniation in patients over 60?
Stenosis with spondylitic changes
72
About what percentage of patients with disc herniations have myelopathy, according to one study?
15%
So important to check all patients with herniations for cord involvement
73
Other than herniation and stenosis, what are the less common causes of cervical cord compression (B-list)?
```
Trauma
Structural instability
Tumor/SOL
Infection
Fracture
Spinal cord adhesions
```
Usually not just spurs or osteophytes
