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Group B – AHD Dr. Gary Greenberg. Spinal Nerve Root Compression and Peripheral Nerve Disorders. Objectives. Review Assessment and Management of Important Spinal Nerve Disorders Involving the Cervical, Thoracic and Lumbar Spine.

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Group B – AHD Dr. Gary Greenberg


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    1. Group B – AHD Dr. Gary Greenberg Spinal Nerve Root Compression and Peripheral Nerve Disorders

    2. Objectives • Review Assessment and Management of Important Spinal Nerve Disorders Involving the Cervical, Thoracic and Lumbar Spine. • Review Assessment and Management of Common Peripheral Nerve Disorders. • Review Assessment of Important • Mono/Polyneuropathies .

    3. Case 1 • 70 year old male, history of mild neck pain for 2 yrs. • Gradual worsening mid cervical pain for 1 month. • Radiating down right arm to hand. • Numbness, tingling and weakness. • Now pain severe, unremitting. • Unable to sleep in spite of taking Tylenol #3. • What historical factors would help you assess this patient?

    4. Historical Factors? • 1) Trauma – recent falls. • 2) Cancer- remote/recent history. • 3) Cervical spondylosis. • 4) Fever, weight loss. • 5) Immunosuppression. • 6) Bone thinning disease ( Rheumatoid arthritis, Multiple Myeloma ).

    5. RED FLAGS • What are some of the RED FLAGS that come up in taking a history that make you think there might be a more serious condition present?

    6. RED FLAGS • Significant trauma pt. < 50 yrs. • Mild trauma pt. > 50 yrs. • Unexplained weight loss. • Unexplained fever. • Immunosupression. • Cancer Hx. • Night pain. • IV drug use.

    7. Red Flags Osteoporosis. Prolonged Steroid use. Age >70. Focal Neuro Deficits. Disabling symptoms. Duration > 6 weeks. Pain not relieved by laying supine.

    8. What physical examination findings would you look for?

    9. Physical Examination Tenderness cervical spine. Motion in the neck Focal weakness Sensory loss Reflex loss

    10. Case 1 • What are some of the causes of Neck Pain + Radicular Pain + Weakness ?

    11. Causes: Neck pain + Radicular pain + Weakness • Idiopathic- congenital spinal stenosis. • Traumatic- fracture. • Degenerative- Disc herniation, foraminal stenosis, cervical spondylosis. • Neoplasm. • Infection.

    12. Neck Pain • Can Cervical Disc Disease cause gait disturbance?

    13. Important notes • Central Disc Disease – can cause gait disturbance, neurogenic bladder, loss of anal tone.

    14. Neck Pain • Are Neoplastic mets to C-spine common?

    15. Important notes • Neoplasm- mets to C-spine 8-20% of all spinal mets.

    16. Neck Pain • What is the classic presentation of Neoplastic mets to the C-spine?

    17. Important notes • Neoplasm- neuro symptoms + severe pain.

    18. Neck Pain • Is fever a common finding in infection of the C-spine?

    19. Important notes • Infection- C-spine least common site, only 50 % have fever.

    20. Neck Pain • Name important risk factors for infection in the C-spine.

    21. Important notes • Infection risk factors- IV drug use, diabetes, alcoholism, malignancy, corticosteroids.

    22. Cervical Radiculopathy • Describe the incidence , Reflex, Sensory and motor loss for the following levels involved: • C5 radiculopathy. • C6 radiculopathy • C7 radiculopathy. • C8 radiculopathy.

    23. What level of Cervical radiculopathy is involved ? • C5 – 2% incidence. Reflex loss- Biceps. • C6- 22% incidence. Reflex loss- None. • C7- 70% incidence. Reflex loss- Triceps. • C8- 6% incidence. Reflex loss- None.

    24. Cervical Radiculopathy Sensory loss C5 - proximal lat. arm • C6- lat. Forearm/thumb. • C7 -2-4th fingers. • C8 - 5th finger.

    25. Cervical Radiculopathy • Motor loss • C5- Deltoid, infra/supraspinatus, biceps. • C6- Biceps, deltoid, brachioradialis, pronator teres. • C7 – Triceps , wrist flexors and extensors. • C8- Thumb abduction, finger flexion and extension.

    26. Cervical Imaging • What is the value of a C-spine x-ray?

    27. IMAGING • X-rays- fractures, confirms degenerative changes.

    28. Cervical Imaging • When should an MRI be ordered?

    29. IMAGING • MRI- shows foramina and discs best.

    30. Cervical Imaging • When should a CT scan be ordered?

    31. IMAGING • CT- Only good for occult fractures.

    32. Neck Pain • How long does it take for most neck pain from non pathological causes to resolve?

    33. Neck pain • Most neck pain resolves in 3-6 weeks.

    34. Neck Pain • What factors may extend that time frame?

    35. Neck pain • Automobile related neck injuries- 20-70% have pain after 6 months. • Work related neck injuries- may last years if not resolved in 8 weeks.

    36. Thoracic Pain • Name some common causes of persistent thoracic back pain.

    37. Thoracic Spinal Nerves • Causes: • Diskitis • Thoracic disc bulge. • Compression fractures- trauma, osteoporosis. • Tumour- most common site in spine .

    38. Thoracic Pain • What is the most common tumor to cause mets to the thoracic spine?

    39. Thoracic Spinal Nerves • Tumour: Lung, Breast, Prostate, Kidney, Thyroid.

    40. Thoracic Pain • If a Thoracic Spinal nerve is compressed, is there motor weakness?

    41. Thoracic Spinal Nerves • Most usually have pain without motor weakness.

    42. Thoracic Pain • If the spinal cord is compressed, what are the clinical findings ?

    43. Thoracic Spinal Nerves • If motor Involvement- often complete weakness of both legs with areflexia due to spinal cord compression.

    44. Case 2 • 45 year old male. • Acute onset low back pain radiating down left leg to toes. • Initial Rx Tylenol & Advil. • After 1 week, severe constant unremitting pain in left leg. • Unable to sit, bend forward , sleep. • What historical features should be asked?

    45. Historical Factors? • 1) Trauma – recent falls. • 2) Cancer- remote/recent history. • 3) Lumbar spondylosis. • 4) Fever, weight loss. • 5) Immunosuppression. • 6) Bone thinning disease ( Rheumatoid arthritis, Multiple Myeloma ).

    46. RED FLAGS • What are some of the RED FLAGS that might come up in a history of low back pain that make you think there might be a more serious condition present?

    47. RED FLAGS • Significant trauma pt. < 50 yrs. • Mild trauma pt. > 50 yrs. • Unexplained weight loss. • Unexplained fever. • Immunosupression. • Cancer Hx. • Night pain. • IV drug use.

    48. Red Flags Osteoporosis. Prolonged Steroid use. Age >70. Focal Neuro Deficits. Disabling symptoms. Duration > 6 weeks. Pain not relieved by laying supine.

    49. Historical features • RED Flags + • Saddle anaesthesia • Bowel symptoms • Bladder symptoms

    50. Questions • What levels are the most common sites for fractures of the lumbar spine? • What levels are the most common sites for disc herniations? • What cancers metastasize to the lumbar spine?