NMS I Heston exam 2

what is the origin of shoulder elbow hand and wrist disorders most commonly

the cervical spineee

Cervical n roots are vulnerable to injury bc they are horizontal

C1 and C2 subluxations can lead to weak what

weak atlantooccipital ligaments

where does the vertebral artery enter thru

C6 TVP foramen

(and ascends beneath the atlantooccip ligament)

what is cervical instability

traumatic injury worsened with upright position but relieved by head support

ADI <3mm adults is normal and <5mm is normal for kids

cervical radiculopathy is what

nonspecific neck pain that radiates to one arm

facet syndrome/muscle strain/ligament sprain is what

neck pain that is worse with movement

cervical myelopathy is what

bilateral neck pain into upper extremities, sometimes including balance issues

upper cross syndrome is what

pain with specific posture changes, (fixed w other postures)

AROM flexion should be what

60 degrees

AROM extension should be what

75 degrees

AROM lateral flex should be what

45 degrees

AROM rotation should be what

80 degrees

make sure pt is supine and only use one inclinometer for this one :)

rust sign

pt spontaneously grasps their head with both hands to take weight off their cervicals.

due to severe pain, RA, fractures, severe subluxations

(check ADI immediatelyyyy)

myelopathy is due to

cord injury!! always pathological (spurs, central disc herniations, tumors, dislocations)

myelopathy S/s

UMN findings! hyperreflexia, spastic extremities, babinski sign, bowel/bladder issues

Lhermitte sign

pt seated, dr passively flexes their head.. cervical myelopathy IF shooting shock like pain into LE/UE

Libman sign

dr puts thumb pressure on pts mastoid processes until pt is too uncomfortable

used to determine pt pain threshold

IVF encroachment is

displacement/irritation of the nucleus, cartilage, apophyseal fragments, annular tissue fragments beyond IVD space

--> obstructed foramina which can irritate or compress the nerve root

MC IVF to be encroached

C6 and C7

MC cuase of IVF encroachment

lateral canal stenosis (osteophytes or ligmentum flavum hypertrophy

cervical disc herniations

s/s IVF encroachment

neck pain and distal paresthesia in a DERMATOMAL distribution

weak muscles supplied by the NR

decreased DTR

muscle fasciculations

worse radiating pain w movments

bakody sign

pt seated putting palm on top of their own head

+= radiating pain DECREASES meaning cervical n root compression BECAUSE elevated suprascapular nerve relieves traction of lower trunk of brachial plexus

what is a better test, spurling or bakody?

BAKODY. no bopping pts head so less pain, and is just as reliable

foraminal compression test

pt rotates head from side to side

dr pushes down on head at neutral and at both rotated sides

+=pain reproduced

LOCAL= foraminal encroachment

RADICULAR= nerve root compression

jackson compression

pt is seated and rotates head. then pt laterally bends and dr presses there and at neutral

+=increased pain.. SOL, subluxation, edema, DDD, tumor, disc herniation

if you perform jacksons compression and find local contralateral pain, what is your diagnosis

muscle strainnnnn

if ipsilateral, can be IVF encroachment (local) or nerve root involvement if radiates

spurling test

pt is seated and rotates head, then laterally flexes and dr pushes down, then laterally flexes and extend head with push

no pain? then dr bops in neutral position

no pain? then dr bops them with lat flex/extended position

+=radicular pain-NR compression

+=local pain=facet

(not for muscle)

distraction test

pt seated, doc does upward pressure to lift pts head

+= relief of radiculat symtoms

= NR compression, facet capsulitis, IVF encroachment

increased pain? muscle spasm

valsalva maneuver

have pt bear down abdominally

+= radiculat pain increased bc increased intrathecal pressure

NR compression by SOL, disc herniation, tumor, osteophyte

dejerine sign

pt coughs, sneezes, strains, defectates

+= increased radicular s/s bc mechanical obstruction of spinal fluid flow

SOL causes nerve root compression, disc nernations -> IVD spinal cord tumor or compression fractures

do intervertebral veins have valves?

NAHHHHRRRR

pressure increases and blocks venous flow which distends veins and forces the dura toward the spinal cord which causes pain w dejerine sign

how should dejerine positive pts cough/sneeze

with knees bent and leaned against a wall

an unexpected absence of dejerine after having it positive previously is a sign of

fragmentation of a disc

naffzinger test

pt seated while dr holds pressure over both jugular veins for 30-40seconds, pt then coughs deeply

+= pain along NR distribution or local pain = sprain/strain

SOL in spinal column, mC spinal meningioma

***CONTRAINDICATED FOR GERIATRICS*******A

swallow test

pt is seated and swallows water

+= difficulty swallowing or pain

SOL, disc protrusion, tumors, osteophytes anteriorly, lig sprains, muscle strains, fractures

what are brachial plexus lesions caused by

MC traction injuries on motorcycles when neck laterally flexes away from the involved side (+ ipsilateral shoulder depression)

ORRRR

weak deltoid, supra/infraspinatus, biceps

brachial plexus tension test

pt holds hands behind head and dr pulls elbows back while pt flexes head

+= radicular pain= NR involvement

erbs palsy

upper brachial plexus (C5,6,7)

difficult births with forceps or vacuums

waiters tip deformity

klumpkes palsy

lower brachial plexus (C8,T1)

breech births, falling and trying to catch yourself by grabbing something

claw hand

upper limb tension test

pt is supine..

1) depress scapula

2) abduct shoulder

3) supinate forearm, wrist/finger extension

4) shoulder externally rotate

5) elbow extension

6) contralat lat bend

7) ipsilat lat bend

+=pain in first 6 steps OR decreased pain in 7th step

shoulder depression test

pt is seated, dr pushes shoulder down and then pt laterally bends neck away

+= radicular pain

brachial plexitis, ADHESIONS OF DURAL SLEEVES, spinal nerve root involvement

bikele test

abduct shoulder to 90 degrees and extend arm behind

+= resistance or increased radicular pain

brachial plexus neuritis, meningitis

brudzinskis test

pt is supine with straight legs, dr passively flexes head

+=BOTH knees buckle- meningeal irritation

kernig sign

pt supine, dr bends one knee to 90 and then straightens it upward, positive if other knee bends = meningeal irritation

o'donoghue maneuver

pt is seated, do all AROMs actively then passively

+= pain AROM?- muscle strain

+=pain PRROM?-ligament sprain

soto hall test

pt is supine and dr puts hands on pts sternum while passivley flexing them

+= local pain in posterior spine

fracture, subluxation, exostoses, disc lesion, strain/sprain

meningeal irritation if knees buckle!!

mild muscle strain

low grade inflammation and minimal swelling/edema

moderate muscle strain

laceration of fibers, hemorrhaging into surrounding tissues, swelling and edema

severe muscle strain

complete disruption of motor units, tendon pulls apart from bone

mild ligament sprain

only a few fibers severed

moderate ligament sprain

more tearing but not complete

sever ligament sprain

complete tear from attachment

sprain/fracture ligament

ligament attachment pulls piece of bone with it (avulsion)

TOS is what

the neurovascular compression of the brachial plexus or subclavian-axillary vessels as they exit the thoracic cavity and enter the UE

neurologic TOS

LOWER trunk of the brachial plexus

abnormal nerve stretch/compression causes it

MC women with DROOPING shoulders

vascular TOS

subclavian artery and vein

unilateral arm swelling

MC in men

what compresses the brachial plexus

1st rib (floor) can trap brachial plexus btwn other structures

TOS presentation

diffuse arm symptoms, pain, numb, tingling, weak grip strength

worse w overhead activities

TOS is MC in

4th/5th digits (C8,T1)

causes of TOS

trauma, posture, tight scalenes, tight pecs, cervical ribs

allen test

pt seated, pumps hands and squeezes

dr occludes radial and ulnar artery then releases one to see refill <5sec normal

+= >5sec refill= vascular occlusion of rad/uln or TOS if both

what runs btween the scalene muscles

the subclavian artery! it then becomes the axillary artery then becomes the brachial artery which breaks into ulnar and radial arteries at the cubital fossa

if blood supply to the hand is occluded it can cause

compartment syndrome

allen maneuver

palpate radial pulse w pts arm at a 90 degrees up. have pt rotate head away

+= pulse lessens/gone=TOS

costoclavicular maneuver

AKA edens test

pt seated and dr palpates bilateral radial pulse and extends arms behind them and pt flexes head forward

+= decreased pulse - TOS

halstead maneuver

dr palpates radial pulse and applies downward traction on arm, pt extends neck and looks up

+= decreased pulse, TOS

reverse bakody sign

pt seated, puts palm on top of head at elbow level w head

+= pain increases in arm/hand

= TOS due to INTERSCALENE COMPRESSION

Roos test

pt is seated and abducts arms to 90 degrees like goal posts

pt holds for one minute then pumps hands for 3min

+= weak/lowered arm or reproduced symptoms-TOS

adson test

palpate radial pulse and have pt turn head TOWARD side and inhale hold for 10sec

+= decreased pulse- TOS bc ANTERIOR SCALENE HYPERTROPHY

modified adson test

palpate radial pulse and have pt turn head AWAY from side and inhale hold for 10sec

+= decreased pulse-TOS bc MIDDLE SCALENE hypertophy (or cervical rib)

hyperabduction maneuver

aka Wrights test

pt seated w arms at sides

palpate radial pulse then abduct arms to 180degrees

+= decreased pulse at DIFFERENT angles

(lower is problematic side)

TOS bc HYPERABDUCTION SYNDROME

superficial reflexes are

motor response to scraping the skin. Either present or absent, asymmetrical is abnormal

they have to ascend to the brain then descend as motor neurons

cremasteric reflex

L1/L2 and ilioinguinal and genitofemoral nerves

stroke inner thigh S->I and ipsilateral testicle should elevate

if not, hydrocele or varicocele

gluteal reflex

L4-S2 and inferior gluteal nerve

stroke skin over glute max and see contraction of muscle

anal wink

S2-S5 and hemorrhoidal nerve

stroke skin of perianal area

contraction of external sphincter= normal

assoc w cauda equina syndrome, SOL

what are pathologic relfexes

superficial and deep reflexes controlled by motor cortex or pyramidal tracts

LMN released/inhibited= primitive responses that are pathological in adults (normal up to 6mo-2yrs)

hoffman sign

corticospinal tract ABOVE C5. flick middle finger down

+= index and thumb come together like Ok sign

=UMN lesion above C5

tromner sign

corticospinal tract above C5

tap VOLAR surface of middle finger upward

+= flexion of fingers and adduction of thumb

UMNL above C5

oppenheim sign

corticospinal tract

stroke anterior tibia S-> I

+=babinski sign-UMNL

babinski sign

corticospinal tract

stroke foot in a 7 shape

+=dorsiflexed big toe and flared other toes

-UMNL

gordons sign

corticospinal tract

squeeze calf

+=babinski, UMNL

rossolimo sign

corticospinal tract

tap ball of foot/tips of toes

+=PLANTARFLEXION of toes - UMNL

chaddock sign

corticospinal tract

lateral malleolus to pinky toe stroke

+=babinski sign-UMNL

schaefer sign

corticospinal tract

squeeze achiles

+=babinski sign-UMNL

pupillary light reflex what is aff what is efferent

aff- Cn2

Eff-Cn3

ciliospinal reflex aff and efferent

aff= cervical pain fibers and CN5

eff-cervical sympathetics

painful side of neck w pinching skin->dilate pupils 1-2mm on painful side

absent? cervical sympathetics problem

HORNER SYNDROME (myosis, ptosis, anhydrosis)

oculocardiac reflex

aff- CN 5

eff- CN 10

press thumbs into eyeballs... HR and BP should decrease

carotid sinus reflex

aff- CN 9

Eff- CN 10

press on carotid sinus

decreased HR and BP

bulbocavernous reflex

S3-S4

stroke/pinch/prick glans of penis

cx of muscle/urethral contraction, anal sphincter cx

muscle reflex dysfunction

decreased reflex and decreased strength

neuromuscular junction dysfunction

stretch reflex decreased and parallel strength loss

peripheral nerve dysfunction

stretch reflex decreases and minimal weakness

nerve root dysfunciton

stress reflexes decreased in proportion to contribution of nerve root

superficial reflexes NOT depressed

cord/brainstem dysfunction

stretch reflexes HYPOactive at level of lesion and HYPERactive below the lesion

cerebellum dysfunction

lesions not associated with stretch reflex changes

not visible normally

basal ganglia dysfuncion

no consistent DTRs or superficial reflex changes

DEMENTIA!

cerebral cortex dysfunction

unilateral diseases affect motor cortex-UMNL

increased muscle stretch reflex

decreased abdominal/cremasteric reflex on CONTRALAT side

emotional expression of reflexes... cry/laugh inappropriatey "PSEUDOBULBAR"

hemicord lesion

AKA brown sequard lesion

1) damage to LATERAL corticospinal tract? = ipsilateral UMN weakness

2) damage to DC?= ipsilateral loss of vibration and joint position

3) damage to ANTERIOR-LATERAL spinothalamic tract?= contralateral loss of pain/temp

transverse cord lesion

partial/complete interruption to ALL motor/sensory pathways BELOW the lesion... weakness/reflex loss

trauma, tumors, MS, transverse myelitis

anterior cord lesion

1) anterolateral pathways (spinothalamic damage)- pain/temp decrease

2) anterior horn cell damage= LMN weakness below lesion

causes- trauma, MS, ANTERIOR SPINAL ARTERY INFARCT!!!!!!!!!!!!,

incontinence common