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Group A – AHD Dr. Gary Greenberg

Group A – AHD Dr. Gary Greenberg. Spinal Nerve Root Compression and Peripheral Nerve Disorders. Objectives. Review Assessment and Management of Important Spinal Nerve Disorders Involving the Cervical, Thoracic and Lumbar Spine.

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Group A – AHD Dr. Gary Greenberg

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  1. Group A – AHD Dr. Gary Greenberg Spinal Nerve Root Compression and Peripheral Nerve Disorders

  2. Objectives • Review Assessment and Management of Important Spinal Nerve Disorders Involving the Cervical, Thoracic and Lumbar Spine. • Review Assessment and Management of Common Peripheral Nerve Disorders. • Review Assessment of Important • Mono/Polyneuropathies .

  3. Case 1 • 70 year old male, history of mild neck pain for 2 yrs. • Gradual worsening mid cervical pain for 1 month. • Radiating down right arm to hand. • Numbness, tingling and weakness. • Now pain severe, unremitting. • Unable to sleep in spite of taking Tylenol #3. • What historical factors would help you assess this patient?

  4. RED FLAGS • What are some of the RED FLAGS that come up in taking a history that make you think there might be a more serious condition present?

  5. What physical examination findings would you look for?

  6. Case 1 • What are some of the causes of Neck Pain + Radicular Pain + Weakness ?

  7. Neck Pain • Can Cervical Disc Disease cause gait disturbance? • Are Neoplastic mets to C-spine common? • What is the classic presentation of Neoplastic mets to the C-spine? • Is fever a common finding in infection of the C-spine? • Name important risk factors for infection in the C-spine.

  8. Cervical Radiculopathy • Describe the incidence , Reflex, Sensory and motor loss for the following levels involved: • C5 radiculopathy. • C6 radiculopathy • C7 radiculopathy. • C8 radiculopathy.

  9. Cervical Imaging • What is the value of a C-spine x-ray? • When should an MRI be ordered? • When should a CT scan be ordered?

  10. Neck Pain • How long does it take for most neck pain from non pathological causes to resolve? • What factors may extend that time frame?

  11. Thoracic Pain • Name some common causes of persistent thoracic back pain. • What is the most common tumor to cause mets to the thoracic spine? • If a Thoracic Spinal nerve is compressed, is there motor weakness? • If the spinal cord is compressed, what are the clinical findings ?

  12. Case 2 • 45 year old male. • Acute onset low back pain radiating down left leg to toes. • Initial Rx Tylenol & Advil. • After 1 week, severe constant unremitting pain in left leg. • Unable to sit, bend forward , sleep. • What historical features should be asked?

  13. Questions • What levels are the most common sites for fractures of the lumbar spine? • What levels are the most common sites for disc herniations? • What cancers metastasize to the lumbar spine?

  14. RED FLAGS • What are some of the RED FLAGS that might come up in a history of low back pain that make you think there might be a more serious condition present?

  15. Sciatica • How often does sciatica due to disc herniation occur in low back pain patients? • How often does sciatica due to disc herniation go on to develop quada equinae? • Generally what nerve root does the L4-5 disk herniation affect? • Why do most sciatica patients get better over time and do not require surgery? • What is the value of SLR, reflexes in the examination of sciatica?

  16. Assessment • Describe the motor , sensory, reflex findings for the following nerve root compressions: • L1 • L2 • L3 • L4 • L5 • S1 • S2-4

  17. Imaging • What is the value of plain x-rays of the lumbar spine? • What is the value of a CT scan of the lumbar spine? • What is the value of MRI of the lumbar spine?

  18. Treatment of Back pain • Most patients have non specific low back pain. • Most have pain resolution in 4 weeks. • Subacute LBP last 4-2 weeks. • Chronic LBP lasts > 12 weeks. • WHAT WOULD BE POSSIBLE TREATMENT OPTIONS FOR LOW BACK PAIN ?

  19. Surgery for Sciatica • What are the indications for surgery for sciatica?

  20. Spinal Stenosis • Describe the features of a patient with Spinal Stenosis?

  21. CaudaEquinae • Describe the clinical features of Cauda Equina. • What are some of the causes? • How do you check for anal tone? • What amount of residual post void urine would qualify as urinary retention? • What is the imaging of choice?

  22. Other Peripheral Nerve Compression Syndromes • Median Nerve Entrapment- Carpal Tunnel, Pronator Teres Syndromes. • Ulnar Nerve Compression- at elbow, at wrist. • Radial Nerve Compression- Spiral groove, posterior interosseus.

  23. Median Nerve Compression • Describe the causes, symptoms and clinical findings of carpal tunnel syndrome?

  24. Median Nerve- Carpal Tunnel Syndrome • Describe the initial treatment for Carpal Tunnel . • Are NSAIDS useful? • Predictive factors for failure of conservative measures? • Place for surgery?

  25. Median Nerve – PronatorTeres Syndrome • What are the different features compared to Carpal Tunnel Syndrome?

  26. Ulnar Nerve Compression • Describe the findings of ulnar nerve compression at the elbow. • Describe ulnar nerve compression at the wrist.

  27. Radial Nerve Compression • Describe the findings of Radial nerve compression at the spiral groove. • Describe the findings of Posterior interosseus Neuropathy.

  28. Mono and Polyneuropathies • Important to know if sensorimotor findings are: • Symmetric or Asymmetric. • Distal or distal and proximal. • Sensory only, Motor only or mixed.

  29. Guillain-Barre Syndrome • Acute Inflammatory Polyradiculoneuropathy. • Immune mediated inflammation of peripheral nerves disrupting myelin and causing axonal loss. • Most common acute motor neuropathy. • Usually has a preceding history of a URI or GI illness preceeding the onset. • Describe the symptoms and findings.

  30. GuillainBarre Syndrome • Describe the lab and imaging abnormalities:

  31. GuillainBarre Syndrome • What is the treatment for GBS?

  32. Distal Symmetric Polyneuropathy • Stocking glove sensory distribution. • Motor findings lag behind sensory. • Progress distal to proximal. • Causes: Diabetes, Alcoholism, Neoplasm, HIV, Toxins, drugs. • Describe the findings in Diabetic neuropathy:

  33. Diabetic Neuropathy • Describe treatment options for Diabetic Neuropathy.

  34. Mononeuropathy Multiplex • Asymmetric Sensorimotor peripheral neuroathy. • Sensory findings match the motor findings. • May have reflex loss depending on the nerve involved. • Name the most common 2 causes:

  35. Anterior horn cell Neuronopathy- ALS • Amyotrophic Lateral Sclerosis. • Asymmetrical distal motor weakness with no sensory loss. • Subclinical Autonomic dysfunction. • Has both Upper and Lower motor neuron signs. • What are they?

  36. ALS • What test confirms the diagnosis. • What are treatment options..

  37. Sensory Neuronopathies • Affects dorsal root ganglions. • Describe the physical findings.

  38. Sensory Neuronopathy • List some causes and diagnostic aides.

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