1. Last week we looked a Thoracic outlet case
Welcome to week 3
Last week we looked a Thoracic outlet case

2. Group assignment

3. Neck pain with severe left arm pain Take a history
Yura Weiner
Neck pain with severe left arm pain
Take a history

4. 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

5. How might you explain The pain complaints The weakness
The numbness and tingling
The palliative behavior

6. Top 3 Differentials

7. 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

8. 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

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

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

11. Differentials Disc / Stenosis Entrapments X-ray MRI
1111
The cervical spine is best studied by standard X-Rays and MRI. Electrophysiological testing should easily rule out ulnar nerve or median nerve entrapments. In a neurogenic TOS, electrophysiological testing is often entirely normal. EMG can sometimes detect neurogenic C8/T1 signs; by electrostimulation, abnormal sensory conduction from ulnar nerve coupled with abnormal median motor conduction may suggest TOS. The diagnosis may also be suggested by somatosensory evoked potentials findings like prolonged conduction latencies between axilla and C-spine (17). On the other hand, the F-wave impairment is not constant: it analyses conduction along a long segment of nerve so that a localized slowing of conduction at the thoracic outlet is easily overlooked. At last, the Erb point stimulation test is inaccurate, usually performed distal to the site of compression.
In some rare cases, diagnosis of TOS is approached on the ground of positive findings. A cervical rib or C7 transversomegaly is a strong argument for the diagnosis of TOS in the adequate clinical context. Some authors have attempted to study the thoracic outlet region by CT scan or MRI/MRA, comparing both the affected and the contralateral sides (2,11). One of the limitations is that the compromise of the neurovascular bundle is often positional and intermittent. Duplex ultrasonography of subclavian artery with positional maneuvers is useful in confirming the clinical impression of artery compression under specific arm conditions. Arteriography/venography are indicated only in the evaluation of vascular types of TOS. An interesting test used by Sanders et al (15) is the scalene muscle block: temporary relief of symptoms following anterior scalene muscle infiltration with 4 cc of 1% lidocaine appears a useful diagnostic tool for TOS. Furthermore, the authors find a high correlation between good response to the block and improvement following scalenectomy.
Differentials
Disc / Stenosis
X-ray
MRI
Entrapments
Electrophysiological evaluation
Often normal in TOS, but positive in distal problems

12. 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

13. The lucky presenter is…

14. Severe Cervical Stenosis

15. Muscle atrophy Which muscles are affected?
What is their nerve root innervation?

16. Stages of Disc Herniation
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Symptoms of a Cervical Herniated Disc
Herniation typically occurs secondary to posterolateral annular stress. Herniation rarely results from a single traumatic incident.
Acute traumatic cervical HNP serves as a major etiology of central cord syndrome.
The C6-C7 disc herniates more frequently than discs at other levels.
Acute disc herniation causes radicular pain through chemical radiculitis in which proteoglycans and phospholipases released from the nucleus pulposus mediate chemical inflammation and/or direct nerve root compression. Interleukin 6 and nitric oxide are also released from the disc and play a role in the inflammatory cascade.
The chemical radiculitis is a key element in the pain caused by HNP as nerve root compression alone is not always painful unless the dorsal root ganglion is also involved.
Herniation may induce nerve demyelination with resulting neurologic symptoms.
Cervical HNP may be resorbed during the acute phase. Indeed, studies documenting frequent herniation resorption and correlating herniation regression with symptom resolution support conservative treatment of cervical radicular pain.
A rare trauma-induced high cervical (C2-C3) HNP syndrome manifests as nonspecific neck and shoulder pain, perioral hypesthesia, more radiculopathy than myelopathy, and more upper limb motor and sensory dysfunction than lower limb symptomology.
Decreased middle and/or lower cervical spine mobility from spondylosis, with consequent overload at higher segments, may precipitate high cervical disc lesions in older patients. A retro-odontoid disc may result from an upwardly migrating C2-C3 HNP. Some case reports describe cervical HNPs causing Brown-Séquard syndrome, as well as atypical nonradicular symptoms in patients with congenital insensitivity to pain.
Cervical radiculopathy results from mechanical nerve root compression or intense inflammation (ie, chemical radiculitis).
Specifically, nerve root compression may occur at the intervertebral foraminal entrance zone at the narrowest segment of the root sleeve anteriorly by disc protrusion and uncovertebral osteophytes and posteriorly by superior articulating process, ligamentum flavum, and periradicular fibrous tissue.[4]
Decreased disc height, as well as age-related foraminal width decrease from inferior Z-joint hypertrophy, may impinge subsequently on nerve roots.
The cervical region accounts for 5-36% of all radiculopathies encountered. Incidence of cervical radiculopathies by nerve root level is as follows: C7 (70%), C6 (19-25%), C8 (4-10%), and C5 (2%).
The most common cause of cervical radiculopathy is foraminal encroachment (70-75%). The cause is multifactorial, including degeneration of the discs and the uncovertebral joints of Luschka and the zygapophyseal joints. In contrast to lumbar spine disorders, HNP in the cervical spine is responsible for only 20-25% of radiculopathies.
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)

17. C7 Radial N Median N Ulnar N 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

18. Disc-related Signs & Symptoms
1818
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

19. 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

20. Diagnosis
Disc herniation C6-C7 affecting function of the nerve

21. 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.

22. End of case

23. Bart
38-year-old male complains of lower neck and shoulder region pain for the past four weeks

24. 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

25. Trigger Points vs. Tender Points
Local tenderness, taut band, local twitch response, jump sign
Singular or multiple
May occur in any skeletal muscle
May cause a specific referred pain pattern
Local tenderness
Multiple
Occur in specific locations that are symmetrically located
Do not cause referred pain, but often cause a total body increase in pain sensitivity

26. Trapezius Trigger Point 1

27. Trapezius Trigger Points 2 & 3

28. Levator

29. Supraspinatus

30. Scalene Muscles

31. Spenius capitis

32. Splenius Cervicis

33. Infraspinatus

34. SCM

35. Suboccipital

36. Subscapularis

37. Teres