Week 3 Flashcards by Beck Forsland

When would you do a low neuro exam?

For patients with neck pain and (5)

no radiating P into extremity or head
no numbness, tingling, weakness in arms or legs
no HA or CN sx
no recent sig trauma
patient under 50 yo

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What are the Pathoanatomical ddx for Acute Traumatic Neck pain? (5)

Sprain
Strain
Facet syndrome
Disc derangement
Fracture

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What are the Pathoanatomical ddx for NON-Traumatic Neck pain? (4)

Facet syndrome *1/3-2/3 of pts with persistent (chronic) neck pain
Disc derangement
Sprain
Strain

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What percent of chronic neck pain patients have facet syndrome?

36 - 67%

Aka 1/3-2/3

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What is the natural history/prognosis for patients with neck and arm sx?

80-90% will resolve w/in 8 weeks

40% will relapse w/in 1 year

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What are the 5 main clues for nerve root lesion

Arm Pain (3 things: Quality *sharp, electrical, burning, stabbing; Location: known dermatomal; Arm > neck P)
Arm Paresthesia
SMR deficits
Big 5 cervical ortho tests
Spinal loading procedures

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What are the “big 5” cervical ortho tests?

Cervical compression
Cervical distraction
Shoulder ABD
Valsalva
ULTT - median nerve

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A list for radicular pain syndromes in the neck

A list for cord compression

NR:
1 - Osteophyte
2 - Disc herniation
3 - Stenosis

Cord:
1 - Disc hern
2 - Stenosis

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B list for radicular pain syndromes in the neck

B list for cord compression

NR:
1 - Structural instab
2 - Tumor/SOL
3 - Infection
4 - NR adhesion
5 - Trauma to NR

Cord:
1 - Tumors/SOL
2 - Structural instab
3 - Cord trauma
4 - Fx/dislocation
5 - Cord adhesions
6 - Infection

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What MOI can cause Trauma to NR directly?

Compression
Hyperextension
Lateral flexion with shoulder depression
Hyperflexion
Arm traction * brachial plexus only

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C list for radicular pain syndromes in the neck

Disc derangement
Facet syndrome
Joint dysfunction

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What is the 1st thing you do with a patient?

What is the 2nd thing?

3rd thing?

Disease or injury?

Is there nerve damage? (with the 5 things list)

Find the pathoanatomical dx (use the A, B, C lists), then biomechanical dx, and complicators or contributors

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Indications for radiographs? (4)

1 - Trauma
2 - Red flags
3 - Neuro Sx (cord/radicular)
4 - Nonresponsive >1 month failed conservative care

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HIGHEST Indications for cervical MRI in disc cases after radiographs have been taken?

1 - Myelopathy
2 - Progressive MOTOR deficit
3 - Non-responsive to conservative care
4 - Presurgical exam

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What blood tests in blood chem panel may point to bone cancer?

Alk phos = bone building disease
Ca2+ levels = bone breakdown disease
Proteins = MM

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How does syringomyelia present?

Diffuse “cape-like” distribution of pain/temp loss over 1 or 2 shoulders

What cervical conditions do oral corticosteroids put the patient at risk for? (2)

Osteoporosis

Ligamentous instability especially the upper cervicals

How do you perform arm squeeze test? How do you interpret it?

When there is NR compression, 1+ nerves of the arm are sensitive to moderate compression of the biceps and triceps area and should be more painful than other areas of the shoulder and upper arm.

Positive test hurts 3+ more or during the pressure on the middle 1/3 of the upper arm, compared with compressing the AC and anterolateral-subacromial areas.

E.g. if the shoulder hurt 1/10 but arm hurt 4/10 that suggests it may not be a shoulder problem but a nerve problem from the neck.

Atypical presentations of cardiac distress are usually found in people who are (3)

Older patients
Non smokers
no previous Hx of angina

If you take your hands away form the neck when performing Kemps, what do you chart that as?

Quadrant test

What is the clinical decision rule for facet syndrome?

What is the +LR?

positive ER test
P with static palp over facet
restriction to PA joint glide

+LR 4.95

What 2 types of clues to focus on when you think there are nerve root problems?

1 - Deficits and

2 - Paresthesia distribution (NOT pain) is more predictive than pain distribution

What are the 3 top indicators of a C8 radiculopathy in order?

Sensory loss in the little finger
Diminished triceps reflex
Weak finger flexion

Which of the 5 big cervical ortho tests are sensitive?

ULTT—median n. is sensitive

The other 4 are not.

What does it mean when e.g. valsalva is not sensitive?

If valsalva is negative, it isn’t very useful. Useful when it’s positive, not useful as an individual test when it is negative

Age range for cervical disc herniation?

40-60 Peak age 50-54 Rare <30 but not impossible

What pattern of physical exam procedures and their findings would suggest a nerve root that was most susceptible to compressive forces? (4)

AROM: extension, ips-rotation/lateral flexion AROM: flexion, contra-rotation/lateral flexion Cervical compression Cervical distraction

What pattern of PE procedures and their findings would suggest a nerve root that is more sensitive to tension forces? (2)

ULTTs Shoulder abd test/ Bakody’s sign

What are the key indicators to order a cervical radiographic series?

* Moderate to high load trauma * Red flag for disease * Cord/Radicular sign/sx * Non responsive cases

What are the HIGHEST indicators for when to order an MRI in a patient with a cervical disc herniation? (AKA standard of care)

◦ suspicion of myelopathy ◦ progressive deficit ◦ non responsive to conservative care ◦ pre-surgical exam

What is standard of care?

When you practice and do what any reasonable doctor would do

What is medical necessity?

You have enough evidence to justify a particular Tx or study You need to prove that the study is a reasonable step

What are things to do in office for disc herniation?

McKenzie evaluation - can try for acute pt Neuromobilization - NOT acute pt: wait a few weeks Manipulation

What does a manipulation schedule look like for a cervical disc herniation patient?

Manipulation 3-5x/week for 2-4 weeks then 1-3x/week

What is the prognosis for cervical disc herniation patient?

50% better in 2-4 weeks 70% better in 1 month 86% better in 3 months

If your patient has pain or paresthesia along the Medial side of the hand (little finger), where in the nervous system might the lesion be?

* Lower brachial plexus injury e.g. TOS, tumor, stretch trauma “plexitis or plexopathy” * Ulnar nerve entrapment or nerve root “neuritis or neuropathy” * MFTPs * Nerve root “radiculitis or radiculopathy”

What specific muscles with MFTPs might project pain into the medial hand (little finger)?

* Latissimus dorsi * Serratus anterior * Pectoralis Major or Minor