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OR24 Orthopedics
Spine
Toronto Notes 2019
Table 14. Cervical Radiculopathy/Neuropathy
Root C5
Motor Deltoid Biceps
Wrist extension
Sensory Axillary nerve (patch over lateral deltoid)
Reflex Biceps
X-Rays for C-Spine
• APspine:alignment
• APodontoid:atlantoaxialarticulation • lateral
C6
Biceps Brachioradialis
Thumb
Biceps Brachioradialis
C7
Triceps
Wrist flexion Finger extension
Index and middle finger Triceps
C8
Interossei Digital flexors
Ring and little finger Finger jerk
■ vertebral alignment: posterior vertebral bodies should be aligned (translation >3.5 mm is abnormal) ■ angulation: between adjacent vertebral bodies (>11° is abnormal)
■ disc or facet joint widening
■ anterior soft tissue space (at C3 should be ≤3 mm; at C4 should be ≤8-10 mm)
• oblique:evaluatepediclesandintervertebralforamen
• ±swimmer’sview:lateralviewwitharmabducted180°toevaluateC7-T1junctioniflateralviewis
inadequate
• ±lateralflexion/extensionview:evaluatesubluxationofcervicalvertebrae
Differential Diagnosis of C-Spine Pain
• neckmusclestrain,cervicalspondylosis,cervicalstenosis,RA(spondylitis),traumaticinjury,whiplash, myofascial pain syndrome
C-SPINE INJURY
• seeNeurosurgery,NS34 Thoracolumbar Spine
General Principles
• spinalcordterminatesatconusmedullaris(L1/2)
• individualnerverootsexitbelowpedicleofvertebra(i.e.L4nerverootexitsbelowL4pedicle)
Special Tests
• straightlegraise:passiveliftingofleg(30-70°)reproducesradicularsymptomsofpainradiatingdown posterior/lateral leg to knee ± into foot
• Laseguemaneuver:dorsiflexionoffootduringstraightlegraisemakessymptomsworseor,iflegisless elevated, dorsiflexion will bring on symptoms
• femoralstretchtest:withpatientprone,flexingthekneeoftheaffectedsideandpassivelyextendingthe hip results in radicular symptoms of unilateral pain in anterior thigh
Table 15. Lumbar Radiculopathy/Neuropathy
Root
Motor
Sensory
Screening Test Reflex
Test
*Unreliable
L4
Quadriceps (knee extension + hip adduction)
Tibialis anterior (ankle inversion + dorsiflexion)
Medial malleolus
Squat and rise Knee (patellar) Femoral stretch
L5
Extensor hallucis longus Gluteus medius (hip abduction)
1st dorsal webspace and lateral leg
Heel walking Medial hamstring* Straight leg raise
S1
Peroneus longus + brevis (ankle eversion)
Gastrocnemius + soleus (plantar flexion)
Lateral foot
Walking on toes Ankle (Achilles) Straight leg raise
Differential Diagnosis of Back Pain
1. mechanical or nerve compression (>90%)
■ degenerative (disc, facet, ligament)
■ peripheral nerve compression (disc herniation)
■ spinal stenosis (congenital, osteophyte, central disc) ■ cauda equina syndrome
2. others (<10%)
■ neoplastic (primary, metastatic, multiple myeloma)
■ infectious (osteomyelitis, TB)
■ metabolic (osteoporosis)
■ traumatic fracture (compression, distraction, translation, rotation) ■ spondyloarthropathies (ankylosing spondylitis)
■ referred (aorta, renal, ureter, pancreas)