Cervical radiculopathy*
• GREEN |
• Intro: |
- Compression or impairment of the nerve root, causing px & Ssx that extend beyond the neck
- Px in one or both UL which corresponds to the dermatome of the corresponding affected nerve
- Muscle weakness & impaired deep tendon reflexes are common due to nerve impingement
- Neck pain is a common issue, up to 40% of work absenteeism attributed to it |
• Aetiology (risk factors): |
- Conditions causing compression or irritation of spinal nerve root lead to radicular Ssx
- In younger pts (30-40s), disc trauma & herniation are most common causes
- In older pts, degenerative changes become more prevalent
- 50-60s - disc degeneration is most common cause
- 70s - foramina narrowing due to arthritic change is a frequent cause
- Cx radiculopathy less frequent than Lx radiculopathy
- Incidence rate: approx. 85 / 100,000
- C7 nerve root most commonly affected, flooded by C6
- Risk factors: manual labour w/ heavy lifting, driving, operating vibrating equipment
- Chronic smoking Hx increases risk of radiculopathies |
• Pathophysiology: |
- Primarily involves inflammation
- Inflammation often caused by acute herniation of a Cx disc pressing on the nerve root
- Inflammation can worsen degenerative changes, such as osteophytes or disc dehydration, affecting the nerve root
- Direct compression of the nerve root causes px, numbness, tingling, & weakness |
• Clinical presentation: |
- Pts present w/ radicular px or weakness
- Inquire: occupational risk factors, Hx of trauma, & px patterns
- Typically unilateral, but B cases are rare
- B presentations can complicate physical Dx
- Cases of trauma or B involvement necessitate advanced imaging for accurate Dx |
• Physical examination: |
- Reflexes, compare B
- Reflexes usually reduced
- Reduced muscle strength, innervated by the affected nerve (major sign)
- Spurling test: compresses foramina to Dx radiculopathy (px radiates down ipsilateral side)
- Cx distraction: in some cases may relieve Ssx |
• Diagnosis: |
- X-rays are first step
- CT used in traumatic scenarios
- MRI is the preferred modality
- Electromyography is useful in confirming dysfunction of the affected nerve |
• Management: |
- Around 85% resolve within 8-12 weeks
- NSAIDs
- Cx pillows
- Acupancture
- Nerve flossing
- SMT / STW |
• Ddx: |
- Brachial plexus injury in sports
- Cx disc injuries
- Cx discogenic px s.
- Cx facet s.
- Cx spine sprain
- RC injuries
- Strain injuries |
Pancoast syndrome
• YELLOW |
• Intro: |
- Pancoast s. should be distinguished from Pancoast tumour itself
- Entails: ipsilateral shoulder & arm px, paresthesia, paresis, atrophy of the thenar muscles, & Horner's s. (ptosis, miosis, anhidrosis)
- 1° bronchogenic carcinoma is the most frequent cause of Pancoast s.
- Manifests as radiating parascapular px, atrophy of intrinsic hand muscles, & a lung apex density w/ localised rib & vertebrae destruction |
• Aetiology (risk factors): |
- 1° caused by tumours in the superior sulcus of the lung, mostly non-small cell lung cancer (NSCLC)
- NSCLC accounts for 80-85% of all lung cancer cases, w/ Pancoast s. making up 3-5% of these
- Squamos cell carcinoma used to be most common type of NSCLC associated w/ Pancoast s.
- Other malignancies can also cause it
- Rarely, being tumours cause it
- Lung cancer is 2nd most common cancer & is the leading cause of oncological mortality globally |
• Pathophysiology: |
- Pancoast or superior sulcus tumours cause Pancoast s. - Ssx inc. shoulder & arm px due to compression of the brachial plexus - Initial Ssx often misDx as MSK - Tumour extension can lead to C8-T1 radiculopathy (px & paresthesia of the dermatomes) - Weakness of intrinsic hand muscles affects fine motor skills & handgrip - Involvement of sympathetic trunk & Cx ganglion can cause facial flushing & sweat - Harlequin s. may occur w. contralateral flushing & sweating due to hyperactive sympathetic reaction |
• Clinical presentation: |
- Encompasses Ssx related to tumours affecting the lung apex
- Ssx arise due to brachial plexus & associated structures involvement
- 1° Ss: shoulder or arm px & paresthesia along the medial half of the 4th & 5th finger, hand, arm, & forearm (C8-T1 radiculopathy)
- Pulmonary Ssx, e.g. SOB, develop as the tumour progresses to involve more of the lung |
• Physical examination: |
- Ipsilateral facial flushing & sweating due to involvement of sympathetic trunk & Cx ganglion
- Horner s. (ptosis, miosis, anhidrosis) may also develop w/ further disease |
• Diagnosis: |
- Chest x-ray: initial screening, shows increased size of apical cap or lung mass
- CT: provides additional info on tumour extent, satellite nodules, mediastinal adenopathy; crucial for staging
- MRI: done after Dx & before surgery to identify vascular, brachial plexus involvement
- CT-guided core biopsy: Dx test of choice due to outer tumour location |
• Complications: |
- Surgical: atelectasis (partial lung collapse), px, chest wall deformity, frozen shoulder, CSF leak, prolonged air leak, injury to the brachial plexus
- Chemotherapy: side effects of the drugs
- Radiation: alopecia, nausea, vomiting, leathery skin, poor wound healing |
• Management: |
- Good prognosis: early-stage Dx
- Poor prognosis: advanced disease, poor performance status, & weight loss
- Standard care procedure: chemo-radiation followed by surgical resection
Contraindication to surgical resection:
- Presence of mets
- Involvement of ipsi/contralateral mediastinal nodes or supraclavicular nodes
- Involvement of VB >50%
- Involvement of oesophagus &/or trachea
- Involvement of brachial plexus above T1 nerve root |
• Ddx: |
- Other malignancies either 1°, or even being tumours are known to cause Pancoast s.
- Even apical lung infections or abscesses can cause Pancoast s. if they involve the chest wall & surrounding structures |
Thoracic outlet syndrome (TOS)*
• GREEN |
• Intro: |
- Encompasses various conditions involving compression of neurovascular structures in the Tx outlet
- 5 types: venous, arterial, traumatic, true neurogenic, disputed neurogenic
- Tx outlet: 1st rib, scalenes, & clavicles
- Imaging helps in Dx |
• Aetiology (risk factors): |
- Caused by increased pressure in Tx outlet, often due to anatomical abnormalities, e.g. Tx ribs, space-occupying lesions (e.g. tumours, cysts), or fibrous muscular bands from overuse
- Past trauma & neck positioning are common causes, leading to impingement of vessels or nerves
- 2° causes: trap deficiency or clavicle #, which can decrease the outlet space & increase pressure
- Neurogenic TOS: most prevalent variant, constituting over 90% of cases
- F>M & individuals w/ poor muscle development or posture
- Incidence rate: 3-80 / 1000 |
• Pathophysiology: |
- Caused by compression of structures in the Tx outlet
- Extra ribs from 7th vertebrae are common culprits
- Neck trauma preceded 80% of neurological TOS cases, while 20% were 1° caused by anatomic variants
- B TOS reported w/ B Cx ribs as 1° cause
- Soft tissue components (fibrous muscular bands & tumours/cysts), also contribute to TOS
- Athletes w/ repetitive motions inv. extreme ABD & ER (swimmers) are susceptible to TOS
- Classic presentation in swimmers inc. px, tightness, or numbness in the neck or shoulder area when their hand enters the water
- Other susceptible athletes: baseball, water polo, & tennis players |
• Clinical presentation: |
- Manifests w/ variety of Ssx depending on its cause
- Common complaints inc. nebulous px regardless of etiology
- Venous obstruction Ssx may inc. UL swelling, venous distention, & px from hand to forearm
- Persistent venous TOS can lead to UL DVTs
- Arterial TOS may show colour changes in the UL & diminished pulses
- Ssx may appear gradually due to collateral blood flow, exacerbated by certain positions
- Neurogenic TOS (most common) results from brachial plexus compression
- Ssx inc. vague px, hand muscle atrophy, weakness, & sensory deficits |
• Physical examination: |
- Quick overview of pt's posture
- Check symmetry & ROM of both arms initially
Special tests:
- Neurological exam to evaluate n. compression
- Brachial plexus compression test
- Spurling's test
- Adson maneuver for suspected arterial compression
- Roo's stress test
- Costoclavicular test |
• Diagnosis: |
- Physical exam 1st, further imaging confirms Dx
- Chest or Cx x-ray: 1st imaging step, providing crucial anatomical info
- US only for venous TOS
- Venous dopplers for detecting compression of subclavian / other veins |
• Complications: |
- Rare complications
- Ischemic change could manifest if vascular compromise occurs
- Most complications arise from surgical intervention (iatrogenic n. injury, pneumothorax, bleeding complications) |
• Management: |
- Excellent prognosis (90% of cases resolve Ssx w/ conservative care)
- Lifestyle modifications - avoiding repetitive postural stress & workstation modification
- SMT - Cx, Tx, & 1st rib
- STW - scalenes & pec minor
- Exercises phase 1: Cx retractions, ulnar n. floss, scalene stretch, corner pec stretch
- Exercises phase 2: resisted shoulder retraction
- Surgery in case of severe compression not responding to conservative care |
• Ddx: |
- Pec minor s. (PMS) - commonly confused w/TOS
- Brachial plexus injuries
- Cx spine injuries
- Cx radiculopathy
- SIS
- Elbow or forearm overuse injuries
- AC joint injury
- Nondescript px disorders (due to vague nature of TOS Ssx) |
Complex regional pain syndrome (CRPS)*
• YELLOW |
• Intro: |
- Neuropathic px disorder w/ persistent, disproportionate px beyond typical healing times - Ssx inc. sensory, motor, & autonomic abnormalities - Often follows trauma, #, or surgery, but spontaneous cases also occur - Diagnostic criteria: Budapest criteria- 2 types: no nerve trauma & known nerve trauma (clinically indistinguishable, favouring distal extremities) |
• Aetiology (risk factors): |
- CRPS can occur due to various types or degrees of tissue trauma, inc. even w/o injury or due to prolonged immobilisation
- Common causes: #, surgery, sprains, contusions, crush injuries, & seemingly minor interventions like intravenous line placement
- Psychological distress during physical injury may influence the severity & prognosis
- Incidence varies (higher rates in Netherlands compared to US)
- F>M, peak incidence 61-70 age group
- Upper extremities are more frequently involved than lower extremities
- # are the most common trigger (44-46% of cases)
- Vasomotor Ssx, e.g. swelling, temperature, & colour changes, are common
- Dx tests: 3-phase bone scans & autonomic testing
- Risk factors: asthma, ACE inhibitor use, menopause, osteoporosis, Hx of migraine, & smoking |
• Pathophysiology: |
- Multifactorial mechanisms
- Inflammatory changes
- Immunological changes
- Peripheral sensitisation
- Central sensitisation & neuroplasticity
- Autonomic changes |
• Clinical presentation: |
- Allodynia: non-painful stimuli causing px
- Hyperalgesia: exaggerated px from usually painful stimuli
- vasomotor dysfunction: skin colour & temperature changes
- Sudomotor dysfunction: swelling & sweating changes
- Motor Ssx: weakness, reduced ROM, tremor, dystonia in affected extremity |
• Physical examination: |
- Neuropsychological deficits: executive functioning, memory, word retrieval
- Constitutional Ssx: lethargy, weakness, disruptions in sleep architecture
- Cardiopulmonary inv.: neurocardiogenic syncope, atypical chest px, chest wall muscle dystonia leading to SOB
- Endocrinopathies: low serum cortisol, hypothyroidism
- Urologic dysfunction: increased urinary frequency & urgency, urinary incontinence
- GI dysmotility: nausea, vomiting, diarrhoea, constipation, indigestion
Psychosocial factors:
- Associated w/ worsening depression & anxiety
- Poor function & diminished quality of life
- No specific personality or psychopathology predictors
- Px-related behaviour & catastrophic thinking in pts w/ significant comorbid psychological burden or poor coping mechanisms |
• Diagnosis: |
Budapest criteria
A. They should report continuing px disproportionate to the inciting event
B. They should report at least 1 Ssx in 3/4 following categories:
- Sensory: reports of hyperalgesia &/or allodynia,
- Vasomotor: reports of temperature asymmetry &/or skin colour changes &/or skin colour asymmetry,
- Sudomotor/edema: reports of edema &/or sweating changes &/or sweating asymmetry,
- Motor/trophic: reports of decreased ROM &/or motor dysfunction (weakness, tremor, dystonia) &/or changes (hair, skin, nails)
C. Additionally, they must display at least 1 sign at the time of evaluation in 2 or more of the following categories:
- Sensory: evidence of hyperalgesia (to pinprick) &/or allodynia (to light touch or deep somatic pressure),
- Vasomotor: evidence of temperature asymmetry &/or skin colour changes &/or asymmetry,
- Sudomotor/edema: edema &/or sweating changes &/or sweating asymmetry,
- Motor/trophic: evidence of decreased ROM &/or motor dysfunction (weakness, tremor, dystonia) &/or trophic changes (hair, skin, nails)
D. Finally, there is no other Dx that better explains the Ssx & Sx |
• Complications: |
- Dystonia
- Cognitive executive dysfunction
- Adrenal insufficiency
- Gastroparesis
- IBS |
• Management: |
- Early treatment may improve prognosis
- Reported cases of spontaneous improvement
- Treatment goal: px & discomfort improvement, functional restoration, & disability prevention
- PT & exercise improve ROM, function & reduce disability through endorphin release
- Px education
- NSAIDs / pharmacotherapy
- Behavioural therapy (related to depression)
- Invasive interventions |
• Ddx: |
- Arterial insufficiency
- Gillian-Barre s.
- Hysteria
- Monometric amyotrophy
- Multiple sclerosis
- Peripheral atherosclerotic disease
- Phlebothrombosis
- Porphyria
- Poliomyelitis
- Tabes dorsalis |
Bummer or Stinger*
• YELLOW |
• Intro: |
- Common injury in contact sports
- Reflects upper Cx root or peripheral nerve dysfunction injury
- Occurs due to over-stretching of upper trunk of brachial plexus or compression of C5/C6 nerve root
- Recurrences ar frequent & can result in permanent neurological deficits
- Typically graded as Grade I or Grade II nerve injury |
• Aetiology (risk factors): |
- 1° observed in collision or contact sports (e.g. American football, ice hockey, & rugby)
- Affects 50-65% of collegiate American football players
- High recurrence rate requires attention to minimise the problem |
• Pathophysiology: |
3 primary mechanisms:
- Forceful blow causing depression of shoulder & lateral FX of the neck to the contralateral side, leading to traction of the upper roots of the brachial plexus
- A direct blow to supraclavicular fossa or Orb's point causing a percussive injury
- Head forced into hyperEXT, ipsilateral side FX towards trauma side → narrowing of intervertebral foramen at Cx spine, nerve root compression (common in high-level athletes) |
• Clinical presentation: |
- Immediate, acute traumatic onset of px/ burning/paresthesia/pins & needles/weakness
- Typically presents w/ Ssx circumferentially radiating down the arm
- Reports recent Hx of trauma to the area
- Common in young athletes competing in contact sports
- Previous Hx of burners |
• Physical examination: |
- Shacking of the upper extremity
- Holding upper extremity close to their body
- Atrophy or asymmetry in the neck
- Shoulder depression
- Atrophy of deltoid or supraspinatus
- Altered motor patterns when using the shoulder
- Palpation: tenderness, muscle spasm, vertebral tenderness
- ROM: possible decrease in neck & shoulder mobility
- Strength: deltoid (ABD), supraspinatus (ABD - full can), infraspinatus (ER), biceps (elbow FX), pronator teres (forearm pronation), triceps (elbow EXT), & ADD digits minimi (ABD of 5th digit)
- Sensation: burning, paresthesia, pins & needles (usually present circumferentially)
- Reflexes: triceps & brachioradialis
- Special tests: Spurling's test & Tinel test (supraclavicular fossa) |
• Diagnosis: |
- Usually through clinical examination & past medical Hx
- EMG & NCS: able to determine where the lesion is & its severity
- X-rays: indicate or rule out bone injuries |
• Management: |
- Length determined by severity of injury
- For some recovery may take minutes, for other weeks to months
- Commonly reoccur (up to 87%) |
• Ddx: |
- Necessary to rule out Cx #, dislocation, or spinal cord injury
Alternative/associated Cx injuries inc:
- Assessment & management of concussion
- Transient quadriplegia - B Ssx
- Muscular strain/ligament strain - unlikely to have neurological involvement
- Brachial neuritis - insidious onset
- Radiculopathy - differences in acute presentation |
|
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