OVERVIEW. NEUROSURGICAL ASSESSMENT CERVICAL PROBLEMS Dirk G. Franzen, M.D. WHAT IS THE MOST IMPORTANT PART OF THE PHYSICAL EXAM?

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1 NEUROSURGICAL ASSESSMENT CERVICAL PROBLEMS Dirk G. Franzen, M.D. Neurological Surgery Bluegrass Orthopaedics and Hand Care OVERVIEW SCOPE OF THE PROBLEM PREVALENCE PATHOLOGY ANATOMIC CONSIDERATIONS ASSESSMENT HISTORY PHYSICAL EXAM DIAGNOSTIC TESTS WHAT IS THE MOST IMPORTANT PART OF THE PHYSICAL EXAM?

2 HISTORY ONSET LOCATION/DISTRIBUTION HISTORY OF TRAUMA EXACERBATING/ALLEVIATING FACTORS HISTORY OF SIMILAR PROBLEMS HISTORY OF POSSIBLE CONTRIBUTING MEDICAL PROBLEMS HISTORY Watch the patient Get them to be specific: time, location, types of symptoms Don t assume they know/understand any medical terms they use Have them demonstrate if needed Document the history Avoid the use of, or at least supplement, templates

3 HISTORY GENERALIZATIONS Pain worse in the morning, that gets better after getting up and moving is generally arthritic If someone wakes up with a deficit they didn t have when they went to sleep, think a compressive and/or stretch neuropathy Mechanical pain is worse with activity, better with rest Discogenic pain is worse with loading: upright and/or flexion Facet pain is worse with extension PAIN GENERATORS Annulus Facet Capsule Posterior Longitudinal Ligament (PLL) Muscles Ligaments/tendons Other organ systems MYSOFASCIAL PAIN Felt to be the result of biomechanical overloading of muscle/ tendon Primary Idiopathic: Fibromyalgia Direct stress to myofascial tissues Secondary

4 MYOFASCIAL PAIN CRITERIA Muscles in shortened and/or contracted state Increased tone and/or stiffness Trigger points 3-6 mm nodules in muscles tender, and palpation may reproduce patients pain, and even radiate to affected areas ANATOMIC CONSIDERATIONS DISK Think of the disk as a tire on its side Annulus = ply/rubber Nucleus pulposus = air As the disk ages, the nucleus dries out (tire loses air), and starts to pouch out ie. disk bulge A disk herniation means the nucleus has ruptured through the annulus Subligamentous vs. free fragment ANATOMIC CONSIDERATIONS CERVICAL 7 Cervical vertebrae/8 cervical roots Majority of rotation comes from occiput-c2 Each subaxial segment accounts for about 10-15% of flexion/extension Facets are oriented more inclined horizontal Presence of vertebral arteries Normally lordotic Cervical roots are named for the vertebrae they come out above

5 ANATOMIC CONSIDERATIONS SPINAL CORD Pain and temperature crosses at the level of entry, and runs lateral Vibratory and position sense stay ipsilateral and run posteriorly Motor runs ipsilaterally and exits from the anterior horn RADICULOPATHY Symptoms in the distribution of a particular spinal nerve root(s) Pain is generally more constant, may or may not be exacerbated by movement, may be worsened with Valsalva Pain is in the distribution of the myotome Sensory symptoms are in the distribution of the dermatome Pain comes from inflammation Neurologic deficits come from nerve compression MYELOPATHY Findings seen with dysfunction, damage, compression of the spinal cord L Hermitte s Upper Motor Neuron (UMN) signs: Hyperreflexia Spacticity + Babinski, Crossed Adductor, Hoffmans, clonus, pathologic spread May be masked acutely by spinal shock, or chronically with severe peripheral neuropathies

6 PHYSICAL EXAM TESTS Palpation Motor Strength (five point scale) Sensory Exam - dermatome vs peripheral nerve (split ring finger) vs non-anatomic Reflexes - strength, +/- pathologic reflexes Tinel s, Phalen s Spurling - great specificity, but lousy sensitivity (<30%) CERVICAL RADICULOPATHY VS CARPAL TUNNEL Positive Tinel s, Phalen s - CTS Decreased sensation proximal to wrist, weakness of wrist extension, decreased brachioradialis reflex - c. radic. Significant thenar atrophy - CTS Significant weakness of opposition - CTS Double Crush - both ULNAR NEUROPATHY VS CERVICAL RADICULOPATHY Sensory deficit splits ring finger - ulnar n. Significant hypothenar and 1st DI atrophy - ulnar n. Triceps weakness and/or decreased reflex - cerv. rad. Tinel s at the elbow - ulnar n. C8/T1 radiculopathy -? r/o pancost tumor

7 SHOULDER PAIN Pain is frequently worse with arm overhead (this frequently helps pain/sensory symptoms with cervical pathology) Pain is usually worse with activity Pain usually doesn t go past the elbow Frequently get worse pain when lying on that shoulder Worse pain on passive motion of the joint SPINAL CORD SYNDROMES Transection - anatomic vs physiologic Spinal Shock Brown-Sequard Central Cord Syndrome Stinger and/or spinal cord concussion/contusion

8 CERVICAL ASSESSMENT PRACTICAL SESSION/RADIOLOGY

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10 NEUROSURGICAL ASSESSMENT LUMBAR PROBLEMS Dirk G. Franzen, M.D. Neurological Surgery Bluegrass Orthopaedics and Hand Care OVERVIEW SCOPE OF THE PROBLEM PREVALENCE PATHOLOGY ANATOMIC CONSIDERATIONS ASSESSMENT HISTORY PHYSICAL EXAM DIAGNOSTIC TESTS

11 PREVALENCE 50-80% of people will have LBP/year (15-20% are protracted) 3-4% become temporarily disabled/year 1% become permanently disabled/year LBP is second only to the cold for lost workdays 5th most common cause of hospitalization, and 3rd most for surgery Chronic is present >3 months WHAT IS THE MOST IMPORTANT PART OF THE PHYSICAL EXAM? FACET PAIN Classic definition - back pain without radicular pain, especially after twisting or rotating Typically worse with extension Hip/buttock pain, may have crampy proximal leg pain Frequently have tight/tender paraspinal muscles May be increased with SLRT, but usually no leg pain May, and frequently does, occur with other problems Diagnostic/therapeutic injections may confirm the diagnosis

12 PIRIFORMIS SYNDROME Buttock, posterior thigh, and/or trochanteric area pain May have referred pain more distally May have a positive SLRT, but no neurologic findings Frequently have increased pain with internal rotation and adduction of the hip S-I JOINT PAIN LBP, pain around PSIS, buttock, groin, thigh May get some referred crampy type pain in lateral calf Patient will frequently point to the SI joint as the worst May be brought out by maneuvers that stress the joint Diagnostic injection is the only definitive test HIP PAIN Pain in the hip, groin, front/medial thigh Generally doesn t go past the knee Generally no neurologic symptoms/findings Pain increased with passive motion of the hip Frequently patients also have spine pathology

13 ANATOMIC CONSIDERATIONS LUMBAR The spinal cord ends at the L1-2 level, cauda equina below Usually lordotic, greater lower down Facets are oriented more vertically The sciatic nerve is formed from multiple roots distal to the spine, and cannot be pinched by spinal pathology Degenerative disk disease is NOT a disease Roots come out below the level they re named for PHYSICAL EXAM TESTS Straight Leg Raising Test (SLRT) - better for lower roots, <60 degrees Femoral Stretch Test FABER (Femoral ABduction and External Rotation) Hoover - hand under the heel test Motor, Sensory, Reflexes

14 LUMBAR ASSESSMENT PRACTICAL SESSION/RADIOLOGY

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