WEEK 6 - SERIOUS AND SPECIFIC CAUSES OF SPINAL PAIN Flashcards
(14 cards)
What are red flags related to MSK disorders? - cervical
-
myelopathy / spinal cord compromise
- neck pain
- weakness UL/LL
- paraesthesia
- hyperreflexia
- clumsiness / gait disurbances
-
cervical arterial dysfunction
- acute-onset moderate to severe headache or neck pain
- carotid artery dissection
- vertebro basilar insufficiency
- have you experienced any abnormal headaches?
- acute-onset moderate to severe headache or neck pain
-
upper cervical instability
- RA, ankylosing spondylitis - effect collagen and structures in the area
- do you feel any instability? have you felt increased fatigue?
- RA, ankylosing spondylitis - effect collagen and structures in the area
NIFTIV
-
N - neurological
- Sx suggesting neural conduction impairment
- weakness motor impairment
- B/B function
- Lower limbs
- sensory deficits
-
I - infection
- fever, productive cough, change in sputum, PHx of illness, weight loss
-
F - fracture
- high energy MOI
- low energy - poor bone health
- corticosteroids / anabolic steroids
- osteoperosis + family history
- history of fractures
- mechanical symptoms
-
T - tumour / cancer
- new and unexplained weight loss
- non-mechanical pain
- PMHx (cancer, family)
-
I - inflammatory
- inflammatory symptoms (redness, swelling at joints), mutli-site generalised pain, morning stiffness (20+min)
-
V - visceral
- nausea, associated chest pain + tightness, claminess, SOB, SOBOE, radiated shoulder pain
-
V - vascular
- symptoms having a pulsatile nature
Common alerting factors for red flag conditions
- trauma
- age >65
- non-mechanical pain
- pain that wakes you at night
- unrelenting pain not eased by positional change or rest
- worsening / progressive pain or other symptoms
- cluster of findings that don’t add up
Common thoracic spine region serious causes of pain
-
myocardial ischemia and infarction
- chest pain and referred pain
- risk factors for heart disease
- nausea
-
rib fracture
- trauma
- pain with breathing / coughing
- bruising on skin
-
pneumothorax
- trauma
- shortness of breath
- sharp stabbing sudden chest pain
- rapid breathing
- can be spontaneous
-
visceral
- autonomic alterations
- sweating
- nausea
- blood pressure changes
- autonomic alterations
Common lumbar spine region serious causes of pain
-
Cauda equina syndrome
- bilateral alternating radiculopathy +/- leg pain
- subjective sphincteric problems
- perineal/saddle sensory change
- altered bladder and bowel function
- reduced sensation in saddle region
- progressive bilateral weakness
-
central lumbar spinal stenosis
- diminished space available for the neural and vascular elements in the lumbar spine
- neurogenic claudication
- aching in legs
- bilateral leg symptoms
- develops slowly
- leg pain with walking
- neurogenic claudication
- diminished space available for the neural and vascular elements in the lumbar spine
-
visceral
- kidney stones
- urinary tract infection
- endometriosis
-
vascular
- abdominal aortic aneurysm
- pulsating feeling in abdomen
- older age + family history + risk factors
- abdominal aortic aneurysm
Indications for conducting a neurological screening examination
Symptoms suggesting impaired conduction
- numbness /anaesthesia or paraesthesia
- paresis
- PandN’s/tingling
-
performed day 1 and then monitored
- establish baseline
Indications for conducting an UMN examination?
Uni - and especially bilateral symptoms suggesting impaired conduction
- Numbness/anaesthesia or paraesthesia
- P&N’s/tingling
- Paresis
- Lower limb “stiffness”
- Disturbance of gait, balance or coordination
- Decreased fine motor control/clumsiness in hands
- Performed Day 1 AND monitored!
UMN motor neurons
Clonus - quick sustained dorsiflexion (2 positions) - abnormal 2-3 beats or asymmetrical response
Babinski - drag blunt end of pen along lateral border of foot and across the metatarsal heads - abnormal - extensor response
Hoffman’s sign - stabilise DIP joint of middle finger - perform a quick flick of distal phalanx - abnormal response - any movement of thumb/and or index
Tromner sign - stabilise DIP joint of middle finger - perform a quick flick of distal phalanx in opposite direction - abnormal response - any movement of thumb/and or index
Gait - ataxic gait is a neurological sign indicating a problem with coordination of muscle movements
Lower limb myotome testing
L2 - iliopsoas - resisted hip flexion at 90 deg (unilateral)
L3 - quads - knee extension at 90 deg knee flexion (test unilateral)
L4 - supine - feet turned ‘up and in’ bilateral
L5 - extensor hallucis longus - extension of let and right big toes (test bilateral)
S1 - gastroc + soleus - 5x SL heel raise
UL myotome testing
C4 - levator scapulae - resisted scapula elevation (bilateral)
C5 - deltoid - resisted shoulder abd (unilateral)
C6 - biceps - resisted elbow flexion with forearm supinated
C7 - triceps - resisted elbow flexion
C8 - extensor pollicis longus - resisted extension of distal phalanx of thumb
T1 - intrinsics - resisted phalangeal adduction with MCPJ in 90 deg flexion
Cerivcal PROM/AROM Ax
Throughout
- pain scale 1-10?
- is this the pain you came to see me about?
- are you able to move any further?
- what is stopping you?
Cervical spine AROM
- flexion/ext, rotation, side flex
- movement modifications, more ideal starting alignment, supporting shoulder gurdle,
Thoracic spine mid AROM
- cross arm over chest, stabilise shoulder gurdle
- test thoracic flexion
- side flexion (’right shoulder to right hip’)
- can also be modified by placing hand on head and flexing contralaterally
- thoracic rotation
- can assess with arms raised directly up
- hands place on back of the head
- test thoracic ext
Lumbar spine AROM assessment
- in standing
- reach arms down legs until pain is evoked (lumbar flexion)
- cross arms over and move into lumbar ext
- hands side by side, lateral flexion
- fixate hips with handling, get patient to rotate with arms crossed
- fixate shoulders parallel, promote lateral pelvic translation
Safety netting - level of concern
No concerning features
decision: begin a trial of therapy - revise management if clinical features change unexpectedly
few concerning features
decision: begin a trial of therapy with watchful waiting
begin therapy
revise management if clinical features change unexpectedly
monitor progress closely
some concerning features
decision: urgent referral
Do not begin a trial of therapy
further investigation or referral is warranted
high concerning features
decision - do not begin a trial of therapy
emergency referral is warranted
