Orthopedics Neck

Question 1

Normal Anatomy

Answer 1

Nerve roots sit above vs. below in lumbar vertebrae

Question 2

Neck PE

• General
  
  • The patient is in no acute ______, m___ and a____ are appropriate, al___ and or______ times three.
  • The patient is ambulating with a smooth and symmetric gait putting full weight on both lower extremities with good coordination and balance.
• Inspection
  
  • Gait is with normal coordination and balance and is not ____-based.
  • No visible deformity is noted on inspection. (ky_____?)
  • ____ is intact about the head/neck/shoulder region.
• Also:
  
  • Check sh_____ exam…

Answer 2

• General
  
  • The patient is in no acute distress, mood and affect are appropriate, alert and oriented times three.
  • The patient is ambulating with a smooth and symmetric gait putting full weight on both lower extremities with good coordination and balance.
• Inspection
  
  • Gait is with normal coordination and balance and is not broad-based.
  • No visible deformity is noted on inspection. (kyphosis?)
  • Skin is intact about the head/neck/shoulder region.
• Also:
  
  • Check shoulder exam…

Question 3

Tenderness to Palpation and ROM

• Tenderness to palpation
  
  • Where?
  • Midline /Paraspinal?
  • Palpable (1)?
• Range of motion
  
  • Flexion / Extension
  • ______ Bending / Rotation

Answer 3

• Tenderness to palpation
  
  • Where?
  • Midline / Paraspinal?
  • Palpable step-off?
• Range of motion
  
  • Flexion / Extension
  • Lateral Bending / Rotation

Question 4

Strength

• Strength (keep in mind that there is overlap…)
  
  • C1/2: _______flexion
  • C3: lateral ______
  • C4: scapula elevation AKA (1)
  • C5: _______ abduction
  • C6: Elbow ______ / wrist _______
  • C7: Elbow _______ / wrist _____
  • C8: ______ extension

Answer 4

• Strength (keep in mind that there is overlap…)
  
  • C1/2: cervical flexion
  • C3: lateral bending
  • C4: scapula elevation (shoulder shrug)
  • C5: shoulder abduction
  • C6: Elbow flexion / wrist extension
  • C7: Elbow extension / wrist flexion
  • C8: Thumb extension

Question 5

Sensation and Reflexes

• Sensation
  
  • ______ map
• Reflexes
  
  • Biceps (C__); Brachioradialis (C__); Triceps (C__)
  • Hoffman’s =

Area of reference, C7 =

Answer 5

• Sensation
  
  • Dermatome map
• Reflexes
  
  • Biceps (C5); Brachioradialis (C6); Triceps (C7)
  • Hoffman’s = determine whether your fingers or thumbs flex involuntarily in response to certain triggers

numbness in middle finger

Question 6

Hoffman’s Sign

How to test?

Positive result? What does a positive result mean?

Answer 6

• Flicking middle finger*
• Hyperexcitability of other fingers (other fingers will also contract),* + test means spinal cord compression

Question 7

Common Conditions Neck

• A_____ v. P_____
  
  • Pathology and treatments are similar to lumbar spine
• (1) = an injury to the spinal cord due to severe compression that may result from trauma, congenital stenosis, degenerative disease or disc herniation
• C______ Spine Case

Answer 7

• Axial v. Peripheral
  
  • Pathology and treatments are similar to lumbar spine
• Myelopathy
• Cervical Spine Case

Question 8

Cervical Myelopathy Definition

• ________ of the cervical spinal cord most commonly due to degenerative cervical ________ (____ and ____ to put _____ in the spinal cord) .
• The condition most typically presents in _____ patients with symmetric (1) and (1) in the extremities, hamd (1), and gait (1).
• Treatment is usually surgical (1) and (1) as the condition is associated with (1) progression (flat then gets worse, flat then gets worse).

Answer 8

• Compression of the cervical spinal cord most commonly due to degenerative cervical spondylosis (wear and tear to put pressure in the spinal cord) .
• The condition most typically presents in older patients with symmetric numbness and tingling in the extremities, hand clumsiness, and gait imbalance.
• Treatment is usually surgical decompression and stabilization as the condition is associated with stepwise progression (flat then gets worse, flat then gets worse).

Question 9

Cervical Myelopathy Symptoms

• Neck p____, extremity p_______, ____ness, _____ness, ____ instability
• Sensory Loss / Motor weakness (not always)
  
  • ___ dermatomal/myotomal
• H_____reflexia / H______ sign
• Loss of b______/_____-based gait (posterior column dysfunction)

Answer 9

• Neck pain, extremity paresthesia, weakness, clumsiness, gait instability
• Sensory Loss / Motor weakness (not always)
  
  • NOT dermatomal/myotomal
• Hyperreflexia / Hoffman’s sign
• Loss of balance / wide-based gait (posterior column dysfunction)

Question 10

Cervical Myelopathy Referral

• Referral is recommended for patients who present with (1) and (1) of myelopathy
  
  • Not all require surgery, but many will receive cervical _______

Answer 10

• Referral is recommended for patients who present with signs and symptoms of myelopathy
  
  • Not all require surgery, but many will receive cervical decompression

Question 11

Cervical Spine Case

What is his diagnosis?

What does the MRI show?

• 68 yo male
• Active/healthy
• Was lifting weights (bench press) when he suddenly felt pain in his neck as well as shooting pain down his left arm to his middle finger
• Tried rest, heat, Advil
• After 2-weeks, while he feels a bit better, the neck pain and arm symptoms have continued and he makes an appointment to see you
• Physical:
  
  • Inspection
    
    • Normal gait, not broad-based
    • Skin intact
  • Palpation
    
    • Moderate tenderness in region of lower cervical spine, no palpable step-off
  • ROM
    
    • Full flexion/extension/rotation (but feels stiff and somewhat painful)
  • Sensation
    
    • Intact except slight numbness to left middle finger
  • Motor:
    
    • 5/5 all throughout (which muscle group are you particularly interested in?)
    • C7: Elbow extension / wrist flexion / MF extension
  • Reflexes:
    
    • Normal

Answer 11

C7 Radiculopathy

C7 Herniation

Question 12

C7 Radiculopathy

• Technically, in order to call it radiculopathy (as opposed to radiculitis which just means nerve root irritation), you need some form of (1) (sensory, motor, reflex)
• In this case, since he has some ______ in the C7 distribution, we can make the diagnosis C7 radiculopathy.

Answer 12

• Technically, in order to call it radiculopathy (as opposed to radiculitis which just means nerve root irritation), you need some form of neurologic deficit (sensory, motor, reflex)
• In this case, since he has some numbness in the C7 distribution, we can make the diagnosis C7 radiculopathy.

Question 13

C7 Radiculopathy Treatment

• _______ treatment is successful in 75% - 90% of patients
  
  • Surgical decompression reserved for ______ cases or patients with progressive n_____ deficits.
• In this case → Resolution of symptoms after 5-weeks.
  
  • Me______
  • P _
  • _______ modification (stopped weight-lifting and switched to walking)

Answer 13

• Nonoperative treatment is successful in 75% - 90% of patients
  
  • Surgical decompression reserved for refractory cases or patients with progressive neurologic deficits.
• In this case → Resolution of symptoms after 5-weeks.
  
  • Meloxicam
  • PT
  • Activity modification (stopped weight-lifting and switched to walking)