Evaluation 1.History 1.Ask the right questions 2.Listen to the patient 3.Formulate a diagnosis 2.Examination 1.To confirm your diagnosis, not to make diagnosis 3.Ordering additional tests 1.Again, to confirm or r/o diagnosis.
History Ask the right questions Critical questions 1. Pain location Central/Axial/Paraspinal Refer HA or Arm Sx True Radicular 2. Pain quality Dull ache Sharp shooting –neck, occiput, arm Burning vs. dysesthesia 3. Pain Pattern - Diffuse Discrete 4. Numbness – pattern, location 5. Deficit – pattern/distribution Not so critical questions 1. Pain onset/inciting event 2. Pain provocation 3. Pain diminution 4. Up-to-date Rx
History Listen to the patient Stumbling gait Dropping things Hand falling asleep Skin feels burnt Trouble going upstair Urinary hesitancy No pain Woke up with weakness Slowly getting worse
History Diagnosis formulation Diffuse neck pain, HA, skin burning, TP – myofascial pain. Discrete arm pain, not much neck pain, discrete deficit – radiculopathy Weakness, no pain, no numbness – ALS Hand numbness in median or ulnar pattern- CTS or cubbital Sx Wrist extensor weakness- C7 or radial nerve Radicular sx and entrapment sx - Double crush syndrome (C5 or 6 and CTS, C8 or T1 and ulnar)
Examination to confirm your diagnosis Myofascial pain: Trigger points (supraspinatus, rhomboid, teres), no deficit Myelopathy: spastic gait, hyperreflexia, path reflex Radicular distribution deficit – radicular C5: deltoid, infra/supraspinatus C6: bicep, dorsal forarm, thumb, index finger C7: tricep, index, middle finger, finger, wrist extension C8: 4 th,5 th fingers, volar of forearm, grip weakness T1: under arm, finger extension. Peripheral entrapment CTS: middle 3 fingers, grip weakness, + Phalen Cubittal Sx: last 2 fingers, opponens, + Tinel Radial nerve pathology
Additional Tests to confirm your diagnosis Myofascial pain- EMG/NCV if there is lots of refer Sx Myelopathy: MRI Radicular – MRI Peripheral entrapment – EMG/NCV
Treatment Plan 1.Myelopathy with cord compression – surgery 2.Radiculopathy with deficit – surgery +/- 3.Myofascial Pain – Never surgery 4.Peripheral Entrapment Sx - Maybe 5.Double crush Sx – Depends 6.Radiculopathy and Myofascial Pain - depends