Lecture Final Review I Flashcards
(101 cards)
1
Q
What is the term for the process causing irritation, compression, or dysfunction of one or more of the cervical nerve roots?
A
Radiculopathy
2
Q
What is cervical radiculopathy?
A
Any process that causes irritation, compression, or dysfunction of one or more of the cervical nerve roots
3
Q
A diagnosis of radiculopathy usually implies the presence of ___ of nerve pathology, such as sensory, motor, or reflex changes.
A
objective signs
4
Q
What changes are objective signs of nerve pathology?
A
Sensory, motor, or reflex changes
5
Q
What is the most common cause of cervical radiculopathy?
A
Herniated nucleus pulposis
6
Q
What is herniated nucleus pulposis?
A
Focal displacement of nuclear material outside the peripheral disc margin
7
Q
Is herniated nucleus pulposis more common in the cervical spine or the lumbar spine?
A
More common in lumbar spine by 10:1
8
Q
Cervical radiculopathy due to herniated nucleus pulposis typically occurs in patients ___ years of age.
A
less than 40
9
Q
Why does cervical radiculopathy due to herniated nucleus pulposis typically occur (in patients less than 40 years of age)?
A
Disc desiccation (gradual loss of hydration)
10
Q
Cervical radiculopathy due to herniated nucleus pulposis is often associated with what etiology?
A
Acute trauma
11
Q
Lateral canal stenosis is a common cause of ___ radiculopathy.
A
cervical
12
Q
What causes cervical radiculopathy due to lateral canal stenosis?
A
Boney spurs forming as a result of cervical spondylosis (degenerative changes)
13
Q
True or False
Cervical radiculopathy due to lateral canal stenosis is a result of degenerative changes. Those changes are associated with symptomology.
A
False; changes not always associated
14
Q
Cervical radiculopathy due to lateral canal stenosis typically occurs in patients ___ years of age.
A
greater than 40
15
Q
Which of the following causes of cervical radiculopathy often has a history of acute trauma?
- Herniated nucleus pulposis
- Lateral canal stenosis
A
Herniated nucleus pulposis
16
Q
If a patient has pain in the following areas, which nerve root/disc is likely causing the cervical radiculopathy?
- neck
- shoulder
- medial border of scapula
- upper arm
A
C5 (C4-5 disc)
17
Q
If a patient has pain in the following areas which nerve root/disc is likely causing the cervical radiculopathy?
- neck
- shoulder
- medial border of scapula
- radial upper arm and forearm
- thumb
- index finger
A
C6 (C5-6 disc)
18
Q
If a patient has pain in the following areas which nerve root/disc is likely causing the cervical radiculopathy?
- neck
- dorsal and palmar surfaces of forearm
- medial border of scapula
A
C7 (C6-7 disc)
19
Q
If a patient has pain in the following areas which nerve root/disc is likely causing the cervical radiculopathy?
- neck
- scapula
- ulnar aspect of upper arm and forearm
- ring and little fingers
A
C8 (C7-T1 disc)
20
Q
If a patient has a sensory disturbance in the following areas which nerve root/disc is likely causing the cervical radiculopathy?
- deltoid area
- radial aspect of upper arm
A
C5 (C4-5 disc)
21
Q
If a patient has a sensory disturbance in the following areas which nerve root/disc is likely causing the cervical radiculopathy?
- thumb and index fingers
- radial aspect of hand and forearm
A
C6 (C5-6 disc)
22
Q
If a patient has a sensory disturbance in the following areas which nerve root/disc is likely causing the cervical radiculopathy?
- middle finger
A
C7 (C6-7 disc)
23
Q
If a patient has a sensory disturbance in the following areas which nerve root/disc is likely causing the cervical radiculopathy?
- ring and little fingers
- medial forearm
A
C8 (C7-T1 disc)
24
Q
If a patient has a biceps reflex disturbance, which nerve root/disc is likely causing the cervical radiculopathy?
A
C5 (C4-5 disc)
25
If a patient has biceps and brachioradialis reflex disturbances, which nerve root/disc is likely causing the cervical radiculopathy?
C6 (C5-6 disc)
26
If a patient has a triceps reflex disturbance, which nerve root/disc is likely causing the cervical radiculopathy?
C7 (C6-7 disc)
27
If a patient has loss of motor function in the following muscles, which nerve root/disc is likely causing the cervical radiculopathy?
* deltoid
* biceps
* supraspinatus
* infraspinatus
C5 (C4-5 disc)
28
If a patient has loss of motor function in the following muscles, which nerve root/disc is likely causing the cervical radiculopathy?
* biceps
* brachioradialis
* wrist extensors
C6 (C5-6 disc)
29
If a patient has loss of motor function in the following muscles, which nerve root/disc is likely causing the cervical radiculopathy?
* triceps
* wrist flexors
* finger extensors
C7 (C6-7 disc)
30
If a patient has loss of motor function in the following muscles, which nerve root/disc is likely causing the cervical radiculopathy?
* finger flexors
* abductor pollicis brevis
C8 (C7-T1 disc)
31
Which reflex disturbance is associated with C5 radiculopathy?
Biceps
32
Which reflex disturbance is associated with C6 radiculopathy?
Biceps and brachioradialis
33
Which reflex disturbance is associated with C7 radiculopathy?
Triceps
34
Which reflex disturbance is associated with C8 radiculopathy?
None
35
Where might a patient have sensory disturbances if they have radiculopathy from C5 nerve root?
* Deltoid area
* Radial aspect of upper arm
36
Where might a patient have sensory disturbances if they have radiculopathy from C6 nerve root?
* Thumb and index fingers
* Radial aspect of hand and forearm
37
Where might a patient have sensory disturbances if they have radiculopathy from C7 nerve root?
Middle finger
38
Where might a patient have sensory disturbances if they have radiculopathy from C8 nerve root?
* Ring and little fingers
* Medial forearm
39
What are the three key signs in clinical differential diagnosis of cervical radiculopathy?
1. Spurling sign
2. Relief with manual distraction of the neck
3. Relief of arm pain by placing and resting forearm on top of head (Bakody's sign)
40
What is Spurling sign?
Arm pain with extension, side bending, and axial loading to the affected side (applied by doctor)
Positive finding for cervical radiculopathy
41
What is Bakody's sign?
What is reverse Bakody's sign?
Bakody's sign: **relief of arm pain** by placing and resting patient's forearm on top of the head, suggesting cervical radiculopathy
Reverse Bakody's sign: **increased arm pain** upon same action, suggesting TOS
42
A patient is positive for Spurling sign and Bakody's sign. They also find relief with manual distraction of the neck.
This patient is very likely to have ___, but someone without said condition may not have any of these signs.
cervical radiculopathy
43
What is the term for neck pain radiating into the arms due to a sclerotome-like referral?
Pseudoradiculopathy
44
What is pseudoradiculopathy in regard to neck pain?
Pain radiates into the arms due to sclerotome-like referral
45
How is pain from pseudoradiculopathy distributed?
**Not** a typical dermatomal distribution; **segmentally organized**
Pain is referred to areas arising from the same embryological sclerotome during development
46
Myofascial trigger points in paraspinal musculature and shoulder girdle muscle can cause pain to refer in a ___ pattern, as with pseudoradiculopathy.
sclerotome-like
47
What are some muscles with trigger point patterns that resemble cervical radiculopathy?
* Scalenes
* Infraspinatus
* Supraspinatus
(pseudoradiculopathy)
48
Which vertebrae with joint dysfunction will most commonly cause a sclerotome-like referral of pain into the upper extremity?
C5-6 and C7-T1
(pseudoradiculopathy)
49
Dysfunction of the first costotransverse joint can refer into the arm. These joint dysfunctions are often accompanied by ___.
scalene trigger points
50
Thoracic outlet syndrome involves various neurovascular entrapments that can occur as the ___ passes from the cervical spine, between the anterior and middle scalene muscle and, along with the subclavian artery and vein, under the clavicle and pectoralis minor muscle, and into the upper extremity.
brachial plexus
51
Thoracic outlet syndrome involves entrapment of the brachial plexus.
Which muscles will the brachial plexus pass between when coming from the cervical spine?
Anterior and middle scalenes
52
Why is thoracic outlet syndrome not a true radiculopathy?
TOS is compression of a **peripheral** nerve, not a nerve root
53
Thoracic outlet syndrome involves entrapment of the brachial plexus.
Which muscle will the brachial plexus pass beneath when going into the upper extremity?
Pectoralis minor
54
What are the three major locations for neurovascular entrapment causing thoracic outlet syndrome?
1. Interscalene triangle
2. Costoclavicular triangle
3. Subcoracoid space
55
What is the most common site for neural compression, vascular compression, or both, to cause thoracic outlet syndrome?
Interscalene triangle
56
#TOS
What borders the costoclavicular triangle?
What does the costoclavicular triangle contain?
Bordered by the clavicle, first rib, and scapula
Contains the subclavian artery and vein, and the brachial nerves
57
Which structure within the subcoracoid space is likely to entrap the neurovascular bundle causing thoracic outlet syndrome?
Pectoralis minor tendon
58
What is a primary disease of the shoulder that may cause pseudoradiculopathy?
Rotator cuff tendonitis
59
A ___ is a pathology that can impinge on the lower trunk of the brachial plexus and simulate a C8 nerve root lesion.
pancoast tumor
60
What are five causes of pseudoradiculopathy resembling cervical radiculopathy?
1. Myofascial trigger points (paraspinal or shoulder)
2. Sclerotome-like referral (joint dysfunction, etc.)
3. Peripheral nerve compression (TOS)
4. Rotator cuff tendonitis
5. Peripheral nerve compression caused by pathological process (pancoast tumor)
61
When a patient presents with signs and symptoms of significant and/or progressive myelopathy, ___ of the spinal cord or nerve roots may be indicated.
urgent surgical decompression
62
If a patient with myelopathy has developed ___, a full return of muscle strength would not be expected even after surgical decompression.
muscle atrophy
63
Most patients with cervical radiculopathy will respond well to ___.
nonoperative, conservative managment
64
How are cervical herniated nucleus pulposis cases usually managed?
Usually considered self-limiting; herniated nucleus will be absorbed with time
65
How would cervical herniated nucleus pulposis be treated if disc herniation caused true damage to the nerves?
Damage may be irreversible
66
How commonly do cervical radiculopathy/myelopathy patients need surgery?
Small minority of cases
67
Consider a timely surgical consultation if a cervical radiculopathy/myelopathy patient has:
* Bowel or bladder dysfunction
* Severe motor or sensory loss
* Known disc herniation with a sequestered fragment
68
Patient with cervical radiculopathy symptoms reports bowel and bladder dysfunction.
What does this suggest?
What does this require?
Suggests progressive myelopathy
Requires **immediate** surgical consultation
69
Patient with cervical radiculopathy symptoms has severe motor/sensory loss.
What does this suggest?
Nerve root damage may be **irreversible**
70
In which cases should you consider surgical referral for a patient with cervical radiculopathy?
* Progressive myelopathy
* Progressive neurological deficit
* Intractable pain
(none of which are improving with adequate trial of nonsurgical care)
71
What are the two basic steps in nonsurgical management of cervical herniated nucleus pulposis?
1. Reduce pain as quickly as possible
2. Consider cautiously applied specific adjustments directed at dysfunctional joints, either at HNP level or nearby
72
In what case should you consider referral for narcotic analgesics for a patient with cervical radiculopathy due to acute herniated nucleus pulposis?
Short-term use in carefully selected patients with very severe non-responsive pain
73
How should adjustments be administered to a patient in the acute stage of cervical herniated nucleus pulposis?
* Minimum force necessary
* Avoid adjusting into directions that cause the **peripheralization** of patient's pain
74
Studies demonstrate that manipulation by adequately trained practitioners in patients with cervical HNP can be carried out safely, but its use is controversial.
Therefore, what is necessary before caring for such a patient?
Provide **detailed informed consent** and be sure the patient is agreeable to a trial course of care to manage your risk
75
The mechanism of whiplash causes a relative ___ motion of the head relative to the neck and body.
anterior to posterior (hyperextension)
76
What are some conditions that warrant routine radiographs of the cervical spine?
* **Significant trauma** (many WAD cases)
* Apparent instability (e.g. Rust sign)
* Suspected fracture/dislocation
* No progress or worsening after adequate trial of care
77
What is the standard three view series for cervical radiographs?
* AP
* APOM
* Lateral
78
Beside AP, APOM, and lateral, what are three additional radiographic views of the cervical spine and what do they assess?
* Oblique - assess IVFs
* Flexion/extension - assess suspected instability
* Swimmer's - lateral view of C-T junction
79
How useful is advanced imaging in evaluating and managing typical cases of WAS trauma in the absence of red flags?
Rarely useful
80
What is the purpose of the NEXUS cervical spine rule?
Clinical decision aid primarily intended for emergency physicians considering radiography
81
According to NEXUS cervical rule, radiography is not necessary if the patient satisfies all five low risk criteria.
What are these criteria?
* No midline cervical tenderness
* No focal neurological deficits
* Normal alertness
* No intoxication
* No other injury causing distracting pain
(consider C-spine imaging unless all criteria are met)
82
Which radiography rule is shown to be more sensitive and more specific than NEXUS criteria?
Canadian cervical-spine rule (CCR)
83
According to Canadian cervical-spine rule, which criteria will mean no radiograph is necessary?
* No high-risk factor mandating radiography
* There is a low-risk factor that allows safe assessment of range of motion
* Able to rotate neck actively
84
An uncomplicated case (grade I to II) of WAD typically involves about ___ weeks of total care.
4-20
85
What does acute care (first 1-8 weeks) for an uncomplicated case of WAD consist of?
* Frequent visits (3-7/week)
* Pain management
* Emphasis on early return to work and normal activity
86
What does subacute care (next 2-6 weeks) for an uncomplicated case of WAD consist of?
* Decrease frequency of visits (1-3/week)
* **De-emphasize passive treatments**
* **Emphasize active care**
87
What does rehabilitative care (last 1-6 weeks of total care) for an uncomplicated case of WAD consist of?
* Less frequent visits (1/1-4 weeks)
* Emphasis on self-care
* **Functional restoration**
88
When should you perform a thorough re-evaluation of a WAD case?
After each 6-10 visits or if patient has a significant change in condition
89
What should you do if a patient with WAD is unresponsive to treatment?
Additional 2 week trial of different treatment
90
What should you do if a patient with WAD has no significant progress with treatment or is worsing?
Referral for special studies and/or medical consultation
91
What should be documented during management of WAD cases?
* Progress and functional improvement (demonstrate effectiveness)
* Remaining functional limitations (justify continuing care)
92
What are four factors that may complicate recovery from WAD?
* Past history of four or more episodes of neck pain
* Symptoms lasting more than 1 week prior to presentation
* Severe pain
* Pre-existing cervical pathology
93
What are some recognized risk factors for chronicity of WAD?
* Occupant unaware or out of position at impact
* Older occupant
* Early onset of neck pain
* Severe initial symptoms
* Early onset of numbness
* Prolonged use of cervical collar
* Neck discomfort > 3 months
* Pre-existing degeneration
94
In over half of WAD cases, the most likely source of chronic pain is injury to ___.
facet joints
95
With chronic pain after whiplash, many cases have injury to the facet joints.
What are some other possible sources of this pain?
* Discoligamentous injury
* Chronic myofascial pain
96
What are the keys to effective whiplash management?
* Screen for red flags
* Encourage patient to **remain active** (avoid iatrogenic disability)
97
What is the most current biomechanical theory of concussion and brain injury?
Coup-contrecoup phenomenon
(possible without impact)
98
The brain has considerable amount of freedom to move within the rigid compartment that is the skull.
In the context of concussion, what is the term for this movement?
Brain slosh
99
When there is impact of the brain within the skull, there is direct macroscopic injury and cellular damage due to ___.
slosh effect
100
When brain moves back and forth within the skull impacting its inside surfaces, it initiates a ___ which reverberates through the brain.
shockwave
101
What is the primary mechanism that leads to microscopic cellular and biochemical damage experienced in concussions?
Shockwave due to slosh effect
(brain impacting inside of skull)
