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					 Welcome to week 3


Last week we looked a
 Thoracic outlet case
Group assignment
 Yura Weiner



Neck pain with
severe left arm
     pain

Take a history
                  History

   45 year-old right-hand dominant man
    shipping manager presents with a 2-month
    history of severe left arm pain and
    weakness to the degree that he cannot
    work
   Lower left neck pain 9/10 NPS
   Left trap pain 9/10 NPS
   Feels best with left arm raised with the
    forearm resting on his head
   No real HA complaint
      How might you explain

   The pain complaints
   The weakness
   The numbness and tingling
   The palliative behavior
Top 3 Differentials
          Answer for Each DDx

   What motor findings do you expect? Why?
   What sensory findings to you expect?
   What other findings should you look for?
   What would your examination look like?
   What would you tell your patient?
       ROF
       Chiropractic care
       Treatment time frame etc
         Yura’s Examination


   He had significant weakness in his left
    triceps (+3/5) as well as his left wrist
    flexors (+3/5) and finger extensors (+4/5)
   He had dense numbness involving his left
    index and middle fingers
                 Imaging

   Plain film X-rays
    show mild DJD in
    the posterior
    joints and
    decreased IVD at
    C5-6 and C6-7
                  Imaging

   MRI shows a large
    disc herniation on
    the left at the C6-C7
    level impinging on
    the spinal cord and
    nerve root.
                  Differentials

   Disc / Stenosis
       X-ray
       MRI

   Entrapments
       Electrophysiological evaluation
         Often normal in TOS, but positive in distal
         problems
                   Case Process

   Create a detailed outline of each
    differential
       Definition
       Etiology
       Epidemiology
       Signs & symptoms – including detail about
        relevant anatomy, physiology, dermatome,
        myotome
       Exam findings
       Special studies indicated
The lucky presenter is…
Severe Cervical Stenosis
            Muscle atrophy

   Which muscles are
    affected?
   What is their nerve
    root innervation?
     Stages of Disc Herniation

   Disc Degeneration:
    chemical changes
    associated with aging
    causes discs to weaken,
    but without a herniation
   Prolapse: the form or
    position of the disc
    changes with some slight
    impingement into the
    spinal canal
   Extrusion: the gel-like
     C7

C5

                  Ext Dig. Comm C7
                  Ext Indicus proprius C7
C6
                  Ext Dig. Minimi C7
                  Triceps DTR

C7   Radial N
     C5-T1
                  Flex. Carp. Rad C7
      Median      Flex. Dig. Sup C7
      N           Flex. Dig. Prof ½ C7
C8        C5-T1

      Ulnar N     Flex. Carp. Ulnaris C7
      C5-T1
T1
           Disc-related Signs &
                Symptoms
   C4 - C5 (C5 nerve root) –
       Can cause weakness in the deltoid muscle and
        shoulder pain
       Does not usually cause numbness or tingling

   C5 - C6 (C6 nerve root) –
       Can cause weakness in the biceps and wrist
        extensor muscles
       Numbness and tingling along with pain can
        radiate to the thumb side of the hand
           Disc-related Signs &
                Symptoms
   C6 - C7 (C7 nerve root) –
       Can cause weakness in the triceps and the
        finger extensor muscles
       Numbness and tingling along with pain can
        radiate down the triceps and into the middle
        finger

   C7 - T1 (C8 nerve root) –
       Can cause weakness with handgrip
       Numbness and tingling and pain can radiate
        down the arm to the medial hand
                Diagnosis


   Disc herniation C6-C7 affecting function of
    the nerve
                 Treatment

   Opted for surgery
   C6-C7 anterior
    cervical discectomy
    and fusion (ACDF)
    involving removal of
    the disc from the front
    of the neck,
    replacement with bone
    graft, and placement
    of a plate for
    stabilization of the
    level.
End of case
                    Bart

   38-year-old male complains of lower neck
    and shoulder region pain for the past four
    weeks
                  History

   Involved in an ATV accident on the beach
    in Mexico. He came up over a sand dune
    and lost control of the ATV causing it to
    veer left and his body to go to the right.
    He landed on the sand and immediately
    felt neck pain
   He got back on the ATV and continued his
    day. The next day, he had neck and
    shoulder pain that he rated as 8/10 with
    movement and 6/10 at rest
   He used ice for a day or two and took a
 Trigger Points vs. Tender
          Points
Trigger points                       Tender points

Local tenderness, taut band, local   Local tenderness
twitch response, jump sign
                                     Multiple
Singular or multiple
May occur in any skeletal muscle     Occur in specific locations that are
                                     symmetrically located

May cause a specific referred pain   Do not cause referred pain, but
pattern                              often cause a total body increase in
                                     pain sensitivity
Trapezius Trigger Point 1
Trapezius Trigger Points 2 &
             3
Levator
Supraspinatus
Scalene Muscles
Spenius
 capitis
Splenius Cervicis
Infraspinat
     us
SCM
Suboccipital
Subscapularis
Teres

				
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posted:10/1/2012
language:English
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