IB CSL ORTHO
NEUROLOGICAL EXAMINATION OF NECK & BACK
Dr Y Yeung
Ortho
Fri 27-09-02
Thoracic spine - has rib cage, support, not mobile segment for daily ambulation
Cervical spine more mobile - therefore less stability, increased degeneration
RADICULOPATHY VS MYELOPATHY
Anatomical description about pathology in spine
In examining spine, need to localise pathology
Radiculopathy: disease of nerve roots
Myelopathy: any functional disturbance and/or pathological change in the spinal cord; often used to denote non-specific lesions, as opposed to myelitis. Also, pathological bone marrow changes
RADICULOPATHY
SLIDE
: Cervical radiculopathy
- LMN lesion: LMN passing out from CNS
CLINICAL FEATURES OF RADICULOPATHY
- LMN signs ® (1) - Weakness (2) Sensory loss/ paraesthesia (3) ¯ jerk
- Radiational pain ® shooting pain to corresponding to dermatome
- Muscle wasting in late stage ® due to long-term compression
DIAG: Cervical roots
DIAG: Anatomy
- C1 = atlas
- C2 = axis, odontoid process
- 8 cervical nerve roots
- Cannot X-ray C1/2 in AP view, need open mouth view
- To test whether decreased rotation due to cervical spine or other segments, get Pt to flex neck then lateral rotation
- Transverse process has canal - vertebral artery passes through
DIAG: Dermatome UL
|
LEVEL |
MOTOR |
REFLEX |
SENSATION |
|
C5 |
Deltoid |
Biceps |
Lateral upper arm |
|
C6 |
Wrist extension |
Brachio-radialis |
Radial forearm (incl. thumb) |
|
C7 |
Wrist flexion |
Triceps |
Middle finger |
|
C8 |
Finger flexion |
- |
Ulnar forearm (digits 4+5) |
|
T1 |
Interossei (Hoffmann's sign) |
- |
Medial upper arm |
Note: only C5, 6, 7
® reflexes
DIAG: Cervical disc
- If disc between C5/6 prolapse
® C6 radiculopathy
DIAG: Spurling Test
- Flexion
- Lateral flexion (tilt)
- Axial compression (loading) - by examiner from above
¯ size of already compromised foramen
Very specific for nerve compression at nerve root foramen (radiculopathy)
MYELOPATHY
DIAG
: Cervical myelopathy
- Compression at SC (UMN lesion)
CLINICAL FEATURES OF CERVICAL MYELOPATHY
- UMN signs
- Long tract signs
- Brisk jerks, up-going plantar
- Hand signs of cervical myelopathy
- Spasticity, clonus
- Involving upper and lower limbs
- Pain is not a predominate feature
- Numbness or sensory disturbance
- Motor power - weakness appears in later stage
TESTS FOR CERVICAL MYELOPATHY
Hoffmann's Test (common exam Q)
- Hyperextend wrist, hold distal phalynx on either side
- Rapidly extend the distal phalynx of middle finger by flicking its anterior surface (nail side)
- +ver = (indicating crotch-thalamic dysfunction) if it results in flexion of the IP of thumb and index finger
- Dynamic Hoffmann's test: repeat while Pt flexes and extends the neck (often facilitates response)
Hermit's Test
- Flexion or extension of the neck produces electric shock-like sensations, particularly in the legs
Inverted Radial Reflex
- This highly specific test is +ver if the fingers flex when the radial reflex is elicited
Clonus
Myelopathy Hand
- Indicative of pyramidal tract damage
- Kinetic - inability to flex and extend fingers rapidly; time Pt over 10 sec; N > 20 cycles (10 sec test)
- Postural - deficient adduction, and often extension of the ulnar 1-3 fingers
- Mildest cases: when fingers are extended, the little finger lies in slight abduction (if it can adduct, this position cannot be held for long); Abduction power is normal
- Severe cases: little, ring and sometimes middle finger may abduct, and/or the same fingers may flex and lose their power of extension
Scapulohumeral Reflex
- Compression above C4 level
- C4 ® supraspinatous + central deltoid
- If hyperreflexia, compression above C4 level is likely (although not definite)
LUMBAR SPINE
- Hip flexion (iliopsoas) ® L2,3
- Hip extension (gluteus maximus) ® S1
- Hip abduction (gluteus medius) ® L5
- Hip adduction (adductor brevis/ longus/ magnus) ® L2,3,4
- Knee extension (quads) ® L3,4
- Foot plantarflexion (gastroc-soleus, flex dig long, flex hal long, tibialis post) ® S1
DIAG: Perianal region
Cauda equina syndrome
- Acute nerve compression
- Cord ends at L1-2 \ no typical sensory deficit
- Must test perianal sensation (pin-prick, PR)
- Requires emergency decompression
- If > 12 hr ® irreversible
|
LEVEL |
MOTOR |
REFLEX |
SENSATION |
|
L4 |
Tib anterior
Foot inversion |
Patella |
Arch foot + medial calf |
|
L5 |
Extensor digitorum longus |
- |
Top of foot, toes, shin |
|
S1 |
Peroneus longus/ brevis |
Achilles |
Lat foot incl. little toe |
DIAG: PID and root of compression
- PID usually L4/5 or L5/S1
- Prolapse - Central, Peripheral
- Nerve root below corresponding segment affected (cf. cervical - nerve root above affected)
NERVE ROOT TENSION SIGNS
Straight Leg Raising
Reproduction of radiculopathy pain = +ve (shooting pain)
Lasegue Test
Bowstring Test
- Flex knee and hip to 90 degrees
- Dorsiflex ankle
- Press posterior fossa ® pain = +ve
Crossover Pain
- Disc protrusion at axillar/ medial to contralateral root
- Indicates more centrally prolapsed disc
Femoral Stress Test (L4)
- Nerve root test (upper nerve root lesion)
- Pt on front - extend hip ® +ve = pain radiates to posterior calf
SUSPICIOUS CASE
Waddle signs
- Axial loading
- Lateral rotation
- Light touch
- -ve flip sign (sit up smooth?)
- Compensation case
- No response to Tx
- Multiple crises/ admission/ doctors
RED FLAG SIGNS
Require Hx and further Ix
- < 20 or > 50 yo
- Nocturnal/ rest pain
- Constitutional symptoms - fever, chill, etc
- Hx ca/ infection
- IVDU
- Immunocompromised - transplant, steroids (prone to infection + tumour)
- Progressive deterioration