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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.
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Welcome to week 3 Last week we looked a Thoracic outlet case
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 • Some numbness and tingling in his left index and middle fingers – both sides • Some weakness when he lifts something that requires him to flex his wrist. He feels that although his grip seems strong, it is not as strong as it used to be. • Pain medications have offered little relief • He saw his MD who ordered Injections in his neck, which\ were also of little help
How might you explain • The pain complaints • The weakness • The numbness and tingling • The palliative behavior
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 • Course of the disorder • Treatment • Prognosis
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 nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc • Sequestration or Sequestered Disc: the nucleus pulposus breaks through the annulus fibrosus and lies outside the disc in the spinal canal (HNP)
C7 C5 Ext Dig. Comm C7 Ext Indicus proprius C7 Ext Dig. Minimi C7 Triceps DTR C6 C7 Radial N C5-T1 Flex. Carp. Rad C7 Flex. Dig. Sup C7 Flex. Dig. Prof ½ C7 Median N C5-T1 C8 Ulnar N C5-T1 Flex. Carp. Ulnaris C7 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.
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 few Advil each day for two day. No other care. • Never had anything like this before • Currently, the pain is 2/10 at rest and 6/10 with certain overhead arm movements • No paresthesia or weakness in his arm or hand although he does feel some weakness when lifting over head
