Lecture 12 - Head, Neck and Back Flashcards
TMJ
temporal mandibular joint
is the synovial joint that connects the jaw to the skull
these two joints are located just in front of each ear
each joint is composed of the condyle of the mandible, an articulating disk, and the articular tubercle or the temporal bone
the movements allowed are side to side, up and down, as well as protrusion and retrusion
this complicated joint along with its attached muscles, allows movements needed for speaking, chewing, and making facial expressions
Which type of arthritis is at increased risk of joint destruction of TMJ?
pts with RA
MPD
myofasial pain dysfunction syndrome
pain at the TMJ due to various causes of increased muscle tension and spasm
it is believed that MPD syndrome is a physical manifestation of psychological stress
no primary disorder of the joint itself is present
pain is secondary to events such as nocturnal jaw clenching and teeth grinding
treatment is focused on behavioral modification as opposed to joint repair
Who gets TMJ?
F > M
hx of jaw trauma
MC in 3rd and 5th decade of life
associated with other chronic pain syndromes and depression
Bruxism
teeth clenching
What PE is done for TMJ?
abnormal mandibular movements:
observe opening and closing of the mouth, with attention to any jaw or dental protrusion. Check to see if the upper teeth and lower teeth are aligned. Look for jaw deviation on opening and closing
Decreased ROM of TMJ: measure functional ROM of jaw opening. normal functional opening is 35 - 55mm
Muscles of mastication tenderness: palpate the TMJ and muscles of mastication assessing for muscle tenderness, joint crepitus, or jaw click during opening and closing
Pain with dynamic loading: to elicit pain with dynamic loading, have pt bite on a cotton toll or grasp the mandible on both sides, pressing down and back to compress the TMJ bilaterally
Bruxism: examine the oral cavity and dentition, looking for signs of tooth wear. This exam may be done by the pts dentist
What is the DDx for TMJ?
AOM mastoiditis AOE Gout Temporal arteritis mandibular fracture or dislocation RA
What is the treatment for TMJ?
NSAIDs, muscle relaxers, lifestyle modification
avoid gum
refer to oral surgery for possible:
bite block/splint or other means of reducing bruxism
joint injection
surgery
Cervical spine nerve roots are above or below cervical vertebrae?
above
Radiculopathies
pain in arm or leg which radiates in a dermatomal distribution of a peripheral nerve
pain may be unilateral or bilateral
typically in cervical or lumbar spines, but occasionally in thoracic spine
several causes: trauma herniated disc osteophytes (arthritis) nerve root swelling invasion of cancer into bone or spinal canal
How do pts with radiculopathies present?
pain in localized dermatome
pain often described as “electrical shock” or “tingling” or “pins and needles”
pain often worse with certain positions
often initiated by trauma, heavy lifting, repetitive motions or prolonged sitting
have you lost control of bowel or bladder?
What are early PE findings of radiculopathies?
Early PE:
pain reproducible with stretching of nerve over bone (straight leg raise test for lumbar radiculopathy)
pain reproduced by narrowing the foramen (Spurling’s test - cervical radiculopathy)
pt moves slowly and very carefully
What are later PE findings of radiculopathies?
muscle weakness in affected dermatome
significant sensory loss detectable by pin prick or light touch
diminished reflexes in affected area
What are concerning PE findings of radiculopathies?
MOST CONCERNING PE FINDINGS:
laxity of rectal tone
fecal incontinence or urinary retention
CALL SPINE SURGEON NOW
What imaging is useful in radiculopathies?
lumbar is POINTLESS
cervical spine films with obliques can show foraminal narrowing
MRI is BEST test (CT will do in a pinch)
Disc Herniation
tough connective tissue of intervertebral disc, the annulus fibrosis, ruptures and spills out the gel like nucleus pulposis onto the spinal nerves
significant inflammatory reaction occurs
Disc Bulge
bulging of the annulus fibrosis can also cause compression of the spinal nerves
What is the treatment for radiculopathies?
initial treatment is conservative unless bowel/bladder control is lost:
NSAIDs
PT
brief rest +/- brief rx with opiates
remove the exacerbating factors (lifting, sitting, etc.)
avoid bed rest
avoid systemic steroids
if conservative measures don’t work, can consider:
-epidural steroid injection (lumbar mainly)
-surgery
1 year after initial sxs, those who had surgery and those who did not had the same outcomes
Cervical spinal stenosis
cervical myelopathy
narrowing of the cervical canal causing pressure on the spinal cord typically causing upper motor neuron signs and sxs
MC causes:
disk herniation
osteophyte formation (arthritis)
ligamentum flavum hypertrophy and ossification
What is the clinical presentation of cervical myelopathy?
motor:
earliest finding in triceps and hand intrinsics weakness
clumsiness is common - problems with shirt buttoning and fine motor control
spasticity in LE
bilateral sensory changes:
+/- radicular. often “stocking-glove”
posterior columns (vibration and proprioception) function impaired. + electrical shock pains in the arms
spastic or scissors gait
bladder dysfunciton - urgency and/or retention
hyperreflexia, including upgoing toes and clonus
+Hoffman’s signs
Which imaging test is best for cervical myelopathy?
MRI
note: you can’t look for cervical stenosis if you dont think of it! often missed dx
What will you see on MRI for cervical myelopathy?
hyperintensity within the spinal cord at the area of compression on T2
myelomalacia = cord edema
spinal cord atrophy
