Clin Med Exam 6

8 pairs of cervical nerve roots (C1-C8) exit through the intervertebral foramina to supply the upper extremities

What is the key cervical nerve root anatomy?

Compression/irritation of a cervical nerve root causing neck pain radiating into the shoulder/arm with numbness or weakness

What is cervical radiculopathy?

Age-related cervical spondylosis (most common), herniated disc (especially in younger patients)

What are the two classic causes of cervical radiculopathy?

Neck extension worsens cervical radiculopathy symptoms

What neck movement commonly exacerbates cervical radiculopathy?

Radiating neck pain with arm pain, numbness, weakness, headaches, and occipital pain

What are the classic symptoms of cervical radiculopathy?

Conservative management: rest, activity modification, NSAIDs, physical therapy, ice/heat

What is first-line treatment for cervical radiculopathy?

Progressive neurologic deficits or persistent symptoms despite conservative treatment

When is surgery indicated for cervical radiculopathy?

age-related degeneration/osteoarthritis of the cervical spine

What is cervical spondylosis?

By age 60, approximately 90% of people have cervical spondylosis

What is the classic epidemiology of cervical spondylosis?

Older age, smoking, prior neck injury, prolonged overhead/downward work, heavy lifting, vibration exposure

What are risk factors for cervical spondylosis?

Neck pain, stiffness, muscle spasms, headaches, dizziness, clicking/grinding with neck movement

What are the classic symptoms of cervical spondylosis?

Physical therapy, NSAIDs, heat/ice, injections; surgery only for severe disease

What is the treatment for cervical spondylosis?

destroys pain-transmitting nerves using heat for chronic neck or back pain

What is radiofrequency ablation used for?

Whiplash from acceleration-deceleration MVC

What is the classic mechanism of cervical strain?

Neck pain, cervicogenic headache, shoulder pain, dizziness, tinnitus, blurred vision, sleep disturbance

What are common symptoms of cervical strain?

Early rehabilitation and physical therapy reduce chronic pain after cervical strain

What is an important treatment pearl for cervical strain?

abnormal head tilt/rotation due to cervical muscle spasm or dystonia

What is torticollis?

Sternocleidomastoid spasm causing head tilt toward one side

What muscle is classically involved in torticollis?

Congenital birth trauma, trauma, infection, awkward sleeping position, dopamine blockers (e.g., metoclopramide)

What are common causes of torticollis?

NSAIDs, muscle relaxants, anticholinergics, botulinum toxin injections, physical therapy

What is the treatment for torticollis?

excessive thoracic curvature producing a rounded upper back ("hunchback")

What is kyphosis?

Osteoporosis with vertebral compression fractures is the classic cause of kyphosis in older adults

What is the most common cause of kyphosis in the elderly?

Scheuermann disease causes kyphosis in adolescents

What pediatric condition causes structural kyphosis?

X-ray measures curvature; MRI evaluates tumors/infection; bone density testing evaluates osteoporosis

How is kyphosis diagnosed?

NSAIDs, physical therapy, osteoporosis treatment, bracing (children), surgery for severe deformity

What is the treatment for kyphosis?

collapse of a vertebral body, usually due to osteoporosis

What is a vertebral compression fracture?

Sudden back pain after minimal trauma in an elderly osteoporotic patient

What is the classic presentation of vertebral compression fracture?

X-ray, CT, MRI, or bone scan

How is vertebral compression fracture diagnosed?

Pain control, activity reduction, bracing; surgery for severe cases

What is the treatment for vertebral compression fracture?

lateral spinal curvature >10° measured by Cobb angle

What defines scoliosis?

Adolescent idiopathic scoliosis is the most common type

What is the most common type of scoliosis?

Uneven shoulders, uneven hips, rib hump, trunk leaning to one side

What are classic physical exam findings in scoliosis?

Cobb angle >10° confirms scoliosis

What Cobb angle defines scoliosis?

Curve >25° is significant; >45-50° is severe

What Cobb angle thresholds are clinically important in scoliosis?

only before skeletal maturity

When is bracing most effective for scoliosis?

Surgery generally indicated for curves >40° with progression or severe deformity

When is surgery indicated for scoliosis?

inflammation of the costochondral joints causing reproducible chest wall tenderness

What is costochondritis?

Typically affects adults >40 years and the 3rd-5th costochondral joints without swelling

What is the classic presentation of costochondritis?

Tietze syndrome causes painful swelling of the costochondral junctions in younger patients

How does Tietze syndrome differ from costochondritis?

NSAIDs, activity modification, corticosteroid injections, TENS

What is the treatment for costochondritis?

forward slippage of one vertebra over another

What is spondylolisthesis?

Degenerative disease, congenital defects, or pars stress fracture (isthmic)

What are the causes of spondylolisthesis?

Low back pain with possible leg pain, weakness, or paresthesias from nerve compression

What is the classic presentation of spondylolisthesis?

Low-grade disease: rest, NSAIDs, PT, bracing; high-grade disease: spinal fusion surgery

What is the treatment for spondylolisthesis?

stress fracture of the pars interarticularis

What is spondylolysis?

L5 pars interarticularis

What vertebral level is most commonly affected in spondylolysis?

Lower back pain in young athletes

What is the classic presentation of spondylolysis?

X-ray diagnosis; treat with rest, NSAIDs, PT, and bracing

How is spondylolysis diagnosed and treated?

age-related degeneration of intervertebral discs

What is degenerative disc disease?

MRI is the best imaging study for degenerative disc disease

What imaging best evaluates degenerative disc disease?

Low-impact exercise, PT, medications, steroid injections; surgery only for cord compression

What is the treatment for degenerative disc disease?

protrusion of nucleus pulposus through annulus fibrosus

What is a herniated disc?

Most commonly occurs in the lumbar spine, followed by the cervical spine

Where do herniated discs most commonly occur?

Back or neck pain radiating into an extremity with numbness, tingling, or weakness

What is the classic presentation of a herniated disc?

MRI is the most accurate test for diagnosing a herniated disc

What is the best diagnostic test for a herniated disc?

Rest, medications, PT, injections; surgery for severe neurologic deficits or refractory symptoms

What is the treatment for herniated disc?

obesity, age >30, repetitive lifting, sedentary lifestyle, weak core muscles

What are risk factors for low back pain?

cancer, aneurysm, kidney stones, infection, or cauda equina syndrome

What serious conditions should be considered in low back pain?

inflammatory arthritis affecting the sacroiliac joints and spine

What is ankylosing spondylitis?

Young man with chronic inflammatory back pain improving with exercise

What is the classic presentation of ankylosing spondylitis?

HLA-B27 is strongly associated with ankylosing spondylitis

What genetic marker is associated with ankylosing spondylitis?

Progressive vertebral fusion (ankylosis) causing a rigid spine

What is the hallmark complication of ankylosing spondylitis?

X-ray/MRI and HLA-B27 testing help diagnose ankylosing spondylitis

How is ankylosing spondylitis diagnosed?

Exercise, NSAIDs, DMARDs/biologics, steroid injections, surgery if needed

What is the treatment for ankylosing spondylitis?

irritation/compression of the sciatic nerve causing radiating leg pain

What is sciatica?

Pain radiating from the buttock down the posterior leg with numbness or tingling

What is the classic presentation of sciatica?

Herniated disc

What is the most common cause of sciatica?

MRI is commonly used when imaging is needed for sciatica

What imaging study is commonly used for sciatica?

Ice, heat, NSAIDs, stretching, PT, injections; surgery only for severe cases

What is the treatment for sciatica?

narrowing of the spinal canal causing compression of the spinal cord or nerve roots

What is spinal stenosis?

Lumbar and cervical regions in adults >50 years

Where does spinal stenosis most commonly occur?

Pain, numbness, tingling, or weakness in the back, neck, arms, or legs

What are the symptoms of spinal stenosis?

MRI is the preferred imaging study for spinal stenosis

What imaging best evaluates spinal stenosis?

Heat, exercise, NSAIDs, PT, injections; surgery for severe disease

What is the treatment for spinal stenosis?

a general term for degenerative changes/osteoarthritis of the spine

What is spondylosis?

compression of lumbosacral nerve roots causing bowel, bladder, and lower extremity dysfunction

What is cauda equina syndrome?

Urinary retention or incontinence, saddle anesthesia, bilateral leg weakness

What is the classic presentation of cauda equina syndrome?

Large herniated disc, spinal stenosis, tumor, trauma, infection

What are common causes of cauda equina syndrome?

MRI is the diagnostic test of choice for cauda equina syndrome

What is the best diagnostic test for cauda equina syndrome?

Emergency surgical decompression within 24-48 hours

What is the definitive treatment for cauda equina syndrome?

delayed treatment can cause permanent paralysis and incontinence

Why is cauda equina syndrome an emergency?

Peripheral nerve injury affecting axons or myelin

What is peripheral neuropathy?

One nerve affected; diffuse generalized involvement of multiple peripheral nerves

Differentiate mononeuropathy from polyneuropathy.

Spontaneous tingling, burning, "pins and needles," or electric shock sensations

What are paresthesias?

Painful abnormal sensations triggered by stimulation

What are dysesthesias?

Sensory loss, weakness, decreased reflexes, and chronic muscle atrophy/fasciculations

What are classic clinical findings of peripheral neuropathy?

Upper motor neuron signs

What exam finding argues against peripheral neuropathy?

CBC, ESR, TSH, fasting glucose/HbA1c, vitamin B12, and serum protein electrophoresis

What is the basic laboratory workup for peripheral neuropathy?

EMG evaluates muscle electrical activity; nerve conduction studies distinguish axonal from demyelinating neuropathy

What is the role of EMG/NCS?

Idiopathic etiology in up to one-third of cases

What percentage of peripheral neuropathy remains idiopathic?

Posterior communicating artery aneurysm

What life-threatening condition should be suspected with a pupil-involving third nerve palsy?

Diabetic or hypertensive microvascular ischemia

What classically causes a pupil-sparing third nerve palsy?

Ptosis, "down and out" eye, diplopia, and possible pupillary dilation

What is the classic presentation of CN III palsy?

Acute lower motor neuron facial paralysis involving the entire ipsilateral face

What is Bell palsy?

HSV reactivation

What is the presumed cause of Bell palsy?

Pregnancy and diabetes

What are risk factors for Bell palsy?

Forehead weakness, inability to close the eye, facial droop, and decreased taste over the anterior two-thirds of the tongue

What are classic findings of Bell palsy?

Prednisone started within 72 hours

What is first-line treatment for Bell palsy?

Valacyclovir for severe or near-complete paralysis

When should antivirals be added for Bell palsy?

Eye protection with artificial tears and lubrication

What supportive treatment is essential for Bell palsy?