Differential Diagnosis
Origin | Pain Location | Exacerbation | Physical Examination | Diseases |
Cervical Spine | Back of neck/head + shoulder/upper arm | Neck movements |
1. Limitation of neck motion 2. Tenderness to palpation over the cervical spine |
OA, Osteophytes, Cervical disc herniation, RA, Trama, Whiplash injury, cervical spondylosis, thoracic outlet syndrome |
Brachial Plexus | Supraclavicular region/ axilla/shoulder | Arm and neck movements/maneuvers (ex. external rotation) | Palpable abnormality above the clavicle | Brachial neuritis, metastatic infiltration, radiation damage to the plexus |
Shoulder | Shoulder + (arm) | Shoulder motion |
Tenderness and limitation of movement (internal/external rotation/abduction) sensorimotor and reflex changes (-) |
Rotator cuff injury/tear, subacromial/subdeltoid bursitis, periarthritis or capsulitis (frozen shoulder), tendonitis, and arthritis, MI, Sudeck atrophy or Sudeck-Leriche syndrome |
*Whiplash injury: If NE (+), consider brain, spinal cord injury, or carotid or vertebral artery dissection
Disc Herniation
Definition: tear in outer ring, annulus fibrosis (AF), and bulging of nucleus pulposus (NC). Usu. posterolateral
Most common: 30 ~40 y/o
b/c NC still gelatin-like.
>40 y/o
NC dehydrated, reduced risk of herniation
Table 11-1 Features of the Main Root-Compressive Syndromes Due to Cervical and Lumbar Disc Herniation
INTERVERTEBRAL DISC SPACE |
ROOT AFFECTED |
PAIN REFERRAL |
WEAKNESS |
REFLEX CHANGE |
ADDITIONAL FEATURES |
---|---|---|---|---|---|
C4-C5 |
C5 |
Shoulder, trapezius |
Supra- and infraspinatus deltoid, slight biceps weakness |
Slightly diminished biceps jerk |
|
C5-C6 |
C6 |
Trapezius ridge and tip of shoulder, radiation to anterior upper arm, thumb, and index finger |
Biceps, brachioradialis, extensor carpi radialis |
Diminished biceps and supinator jerk |
Tenderness over spine or scapula and suprascapular region; paresthesias in thumb and index finger |
C6-C7 |
C7 |
Shoulder, axilla, posterolateral arm, elbow, and middle finger |
Triceps, wrist extensors |
Diminished or absent triceps jerk |
Tenderness over medial scapula and supraclavicular region or triceps. May complain of paresthesias in most of the fingers |
C7-T1 |
C8 |
Medial forearm |
Intrinsic hand muscles |
Slight or no decrease in triceps jerk |
Mimics ulnar palsy |
L2-L3 |
L3 |
Anterior thigh, over knee |
Thigh adductor, quadriceps |
Absent or diminished knee jerk |
|
L3-L4 |
L4 |
Anterolateral thigh, medial foreleg |
Anterior tibial, sometimes with partial foot drop |
Diminished or normal knee jerk |
|
L4-L5 |
L5 |
Posterolateral gluteal sciatica; lateral thigh, anterolateral foreleg, dorsal foot, lateral malleolus and great or second and third toe |
Extensor hallucis longus and extensor digitorum brevis; some weakness of anterior tibialis, sometimes with foot drop |
Unaffected (except posterior tibial) |
Pain with straight-leg raising and variant tests; tenderness over fourth lumbar lateral process and lateral gluteal region |
L5-S1 |
S1 |
Midgluteal sciatica; posterior thigh, posterolateral leg, lateral foot, heel, or lateral toes |
Plantar-flexor and hamstring weakness |
Absent or diminished ankle jerk |
Pain with straight-leg raising and variant tests; tenderness over lumbosacral (L5-S1) joint and sciatic notch; discomfort walking on heels |
(From Adam and Victor's Principles of Neurology)
Cervical Disc Herniation
Location:
C7 (70%)
C6 (20%)
C5 and C8 (10%)
Features: 1. Limitated ROM of the neck and exacervation of pain with movement (esp. hyperextension)
2. Compression of spinal cord
Lumbar Herniation
Location:
L4-5
L5-S1
Diagnosis and Level:
Gold standard: MRI
Managements:
1. Analgesic: A. NSAID B. Oral steroids C. Epidural steroid injection
2. Rehabilitation
The majority improve in six weeks and do not require surgery
3. Surgical Indications:
A. Cauda equina syndrome: difficult urination/incontinence/impotence --> Emergent surgery
B. Progressive neurologic deficit
C. Profound neurologic deficit
D. Intractable and persistent pain after 4 ~6 wks of conservative treatment
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