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• GREEN
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• Intro:
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- Compression or impairment of the nerve root, causing px & Ssx that extend beyond the neck
- Px in one or both UL which corresponds to the dermatome of the corresponding affected nerve - Muscle weakness & impaired deep tendon reflexes are common due to nerve impingement - Neck pain is a common issue, up to 40% of work absenteeism attributed to it |
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• Aetiology (risk factors):
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- Conditions causing compression or irritation of spinal nerve root lead to radicular Ssx
- In younger pts (30-40s), disc trauma & herniation are most common causes - In older pts, degenerative changes become more prevalent - 50-60s - disc degeneration is most common cause - 70s - foramina narrowing due to arthritic change is a frequent cause - Cx radiculopathy less frequent than Lx radiculopathy - Incidence rate: approx. 85 / 100,000 - C7 nerve root most commonly affected, flooded by C6 - Risk factors: manual labour w/ heavy lifting, driving, operating vibrating equipment - Chronic smoking Hx increases risk of radiculopathies |
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• Pathophysiology:
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- Primarily involves inflammation
- Inflammation often caused by acute herniation of a Cx disc pressing on the nerve root - Inflammation can worsen degenerative changes, such as osteophytes or disc dehydration, affecting the nerve root - Direct compression of the nerve root causes px, numbness, tingling, & weakness |
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• Clinical presentation:
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- Pts present w/ radicular px or weakness
- Inquire: occupational risk factors, Hx of trauma, & px patterns - Typically unilateral, but B cases are rare - B presentations can complicate physical Dx - Cases of trauma or B involvement necessitate advanced imaging for accurate Dx |
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• Physical examination:
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- Reflexes, compare B
- Reflexes usually reduced - Reduced muscle strength, innervated by the affected nerve (major sign) - Spurling test: compresses foramina to Dx radiculopathy (px radiates down ipsilateral side) - Cx distraction: in some cases may relieve Ssx |
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• Diagnosis:
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- X-rays are first step
- CT used in traumatic scenarios - MRI is the preferred modality - Electromyography is useful in confirming dysfunction of the affected nerve |
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• Management:
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- Around 85% resolve within 8-12 weeks
- NSAIDs - Cx pillows - Acupancture - Nerve flossing - SMT / STW |
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• Ddx:
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- Brachial plexus injury in sports
- Cx disc injuries - Cx discogenic px s. - Cx facet s. - Cx spine sprain - RC injuries - Strain injuries |
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• YELLOW
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• Intro:
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- Pancoast s. should be distinguished from Pancoast tumour itself
- Entails: ipsilateral shoulder & arm px, paresthesia, paresis, atrophy of the thenar muscles, & Horner's s. (ptosis, miosis, anhidrosis) - 1° bronchogenic carcinoma is the most frequent cause of Pancoast s. - Manifests as radiating parascapular px, atrophy of intrinsic hand muscles, & a lung apex density w/ localised rib & vertebrae destruction |
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• Aetiology (risk factors):
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- 1° caused by tumours in the superior sulcus of the lung, mostly non-small cell lung cancer (NSCLC)
- NSCLC accounts for 80-85% of all lung cancer cases, w/ Pancoast s. making up 3-5% of these - Squamos cell carcinoma used to be most common type of NSCLC associated w/ Pancoast s. - Other malignancies can also cause it - Rarely, being tumours cause it - Lung cancer is 2nd most common cancer & is the leading cause of oncological mortality globally |
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• Pathophysiology:
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- Pancoast or superior sulcus tumours cause Pancoast s.
- Ssx inc. shoulder & arm px due to compression of the brachial plexus - Initial Ssx often misDx as MSK - Tumour extension can lead to C8-T1 radiculopathy (px & paresthesia of the dermatomes) - Weakness of intrinsic hand muscles affects fine motor skills & handgrip - Involvement of sympathetic trunk & Cx ganglion can cause facial flushing & sweat - Harlequin s. may occur w. contralateral flushing & sweating due to hyperactive sympathetic reaction |
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• Clinical presentation:
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- Encompasses Ssx related to tumours affecting the lung apex
- Ssx arise due to brachial plexus & associated structures involvement - 1° Ss: shoulder or arm px & paresthesia along the medial half of the 4th & 5th finger, hand, arm, & forearm (C8-T1 radiculopathy) - Pulmonary Ssx, e.g. SOB, develop as the tumour progresses to involve more of the lung |
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• Physical examination:
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- Ipsilateral facial flushing & sweating due to involvement of sympathetic trunk & Cx ganglion
- Horner s. (ptosis, miosis, anhidrosis) may also develop w/ further disease |
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• Diagnosis:
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- Chest x-ray: initial screening, shows increased size of apical cap or lung mass
- CT: provides additional info on tumour extent, satellite nodules, mediastinal adenopathy; crucial for staging - MRI: done after Dx & before surgery to identify vascular, brachial plexus involvement - CT-guided core biopsy: Dx test of choice due to outer tumour location |
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• Complications:
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- Surgical: atelectasis (partial lung collapse), px, chest wall deformity, frozen shoulder, CSF leak, prolonged air leak, injury to the brachial plexus
- Chemotherapy: side effects of the drugs - Radiation: alopecia, nausea, vomiting, leathery skin, poor wound healing |
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• Management:
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- Good prognosis: early-stage Dx
- Poor prognosis: advanced disease, poor performance status, & weight loss - Standard care procedure: chemo-radiation followed by surgical resection Contraindication to surgical resection: - Presence of mets - Involvement of ipsi/contralateral mediastinal nodes or supraclavicular nodes - Involvement of VB >50% - Involvement of oesophagus &/or trachea - Involvement of brachial plexus above T1 nerve root |
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• Ddx:
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- Other malignancies either 1°, or even being tumours are known to cause Pancoast s.
- Even apical lung infections or abscesses can cause Pancoast s. if they involve the chest wall & surrounding structures |
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• GREEN
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• Intro:
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- Encompasses various conditions involving compression of neurovascular structures in the Tx outlet
- 5 types: venous, arterial, traumatic, true neurogenic, disputed neurogenic - Tx outlet: 1st rib, scalenes, & clavicles - Imaging helps in Dx |
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• Aetiology (risk factors):
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- Caused by increased pressure in Tx outlet, often due to anatomical abnormalities, e.g. Tx ribs, space-occupying lesions (e.g. tumours, cysts), or fibrous muscular bands from overuse
- Past trauma & neck positioning are common causes, leading to impingement of vessels or nerves - 2° causes: trap deficiency or clavicle #, which can decrease the outlet space & increase pressure - Neurogenic TOS: most prevalent variant, constituting over 90% of cases - F>M & individuals w/ poor muscle development or posture - Incidence rate: 3-80 / 1000 |
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• Pathophysiology:
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- Caused by compression of structures in the Tx outlet
- Extra ribs from 7th vertebrae are common culprits - Neck trauma preceded 80% of neurological TOS cases, while 20% were 1° caused by anatomic variants - B TOS reported w/ B Cx ribs as 1° cause - Soft tissue components (fibrous muscular bands & tumours/cysts), also contribute to TOS - Athletes w/ repetitive motions inv. extreme ABD & ER (swimmers) are susceptible to TOS - Classic presentation in swimmers inc. px, tightness, or numbness in the neck or shoulder area when their hand enters the water - Other susceptible athletes: baseball, water polo, & tennis players |
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• Clinical presentation:
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- Manifests w/ variety of Ssx depending on its cause
- Common complaints inc. nebulous px regardless of etiology - Venous obstruction Ssx may inc. UL swelling, venous distention, & px from hand to forearm - Persistent venous TOS can lead to UL DVTs - Arterial TOS may show colour changes in the UL & diminished pulses - Ssx may appear gradually due to collateral blood flow, exacerbated by certain positions - Neurogenic TOS (most common) results from brachial plexus compression - Ssx inc. vague px, hand muscle atrophy, weakness, & sensory deficits |
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• Physical examination:
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- Quick overview of pt's posture
- Check symmetry & ROM of both arms initially Special tests: - Neurological exam to evaluate n. compression - Brachial plexus compression test - Spurling's test - Adson maneuver for suspected arterial compression - Roo's stress test - Costoclavicular test |
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• Diagnosis:
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- Physical exam 1st, further imaging confirms Dx
- Chest or Cx x-ray: 1st imaging step, providing crucial anatomical info - US only for venous TOS - Venous dopplers for detecting compression of subclavian / other veins |
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• Complications:
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- Rare complications
- Ischemic change could manifest if vascular compromise occurs - Most complications arise from surgical intervention (iatrogenic n. injury, pneumothorax, bleeding complications) |
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• Management:
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- Excellent prognosis (90% of cases resolve Ssx w/ conservative care)
- Lifestyle modifications - avoiding repetitive postural stress & workstation modification - SMT - Cx, Tx, & 1st rib - STW - scalenes & pec minor - Exercises phase 1: Cx retractions, ulnar n. floss, scalene stretch, corner pec stretch - Exercises phase 2: resisted shoulder retraction - Surgery in case of severe compression not responding to conservative care |
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• Ddx:
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- Pec minor s. (PMS) - commonly confused w/TOS
- Brachial plexus injuries - Cx spine injuries - Cx radiculopathy - SIS - Elbow or forearm overuse injuries - AC joint injury - Nondescript px disorders (due to vague nature of TOS Ssx) |
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• YELLOW
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• Intro:
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- Neuropathic px disorder w/ persistent, disproportionate px beyond typical healing times
- Ssx inc. sensory, motor, & autonomic abnormalities - Often follows trauma, #, or surgery, but spontaneous cases also occur - Diagnostic criteria: Budapest criteria - 2 types: no nerve trauma & known nerve trauma (clinically indistinguishable, favouring distal extremities) |
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• Aetiology (risk factors):
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- CRPS can occur due to various types or degrees of tissue trauma, inc. even w/o injury or due to prolonged immobilisation
- Common causes: #, surgery, sprains, contusions, crush injuries, & seemingly minor interventions like intravenous line placement - Psychological distress during physical injury may influence the severity & prognosis - Incidence varies (higher rates in Netherlands compared to US) - F>M, peak incidence 61-70 age group - Upper extremities are more frequently involved than lower extremities - # are the most common trigger (44-46% of cases) - Vasomotor Ssx, e.g. swelling, temperature, & colour changes, are common - Dx tests: 3-phase bone scans & autonomic testing - Risk factors: asthma, ACE inhibitor use, menopause, osteoporosis, Hx of migraine, & smoking |
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• Pathophysiology:
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- Multifactorial mechanisms
- Inflammatory changes - Immunological changes - Peripheral sensitisation - Central sensitisation & neuroplasticity - Autonomic changes |
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• Clinical presentation:
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- Allodynia: non-painful stimuli causing px
- Hyperalgesia: exaggerated px from usually painful stimuli - vasomotor dysfunction: skin colour & temperature changes - Sudomotor dysfunction: swelling & sweating changes - Motor Ssx: weakness, reduced ROM, tremor, dystonia in affected extremity |
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• Physical examination:
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- Neuropsychological deficits: executive functioning, memory, word retrieval
- Constitutional Ssx: lethargy, weakness, disruptions in sleep architecture - Cardiopulmonary inv.: neurocardiogenic syncope, atypical chest px, chest wall muscle dystonia leading to SOB - Endocrinopathies: low serum cortisol, hypothyroidism - Urologic dysfunction: increased urinary frequency & urgency, urinary incontinence - GI dysmotility: nausea, vomiting, diarrhoea, constipation, indigestion Psychosocial factors: - Associated w/ worsening depression & anxiety - Poor function & diminished quality of life - No specific personality or psychopathology predictors - Px-related behaviour & catastrophic thinking in pts w/ significant comorbid psychological burden or poor coping mechanisms |
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• Diagnosis:
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Budapest criteria
A. They should report continuing px disproportionate to the inciting event B. They should report at least 1 Ssx in 3/4 following categories: - Sensory: reports of hyperalgesia &/or allodynia, - Vasomotor: reports of temperature asymmetry &/or skin colour changes &/or skin colour asymmetry, - Sudomotor/edema: reports of edema &/or sweating changes &/or sweating asymmetry, - Motor/trophic: reports of decreased ROM &/or motor dysfunction (weakness, tremor, dystonia) &/or changes (hair, skin, nails) C. Additionally, they must display at least 1 sign at the time of evaluation in 2 or more of the following categories: - Sensory: evidence of hyperalgesia (to pinprick) &/or allodynia (to light touch or deep somatic pressure), - Vasomotor: evidence of temperature asymmetry &/or skin colour changes &/or asymmetry, - Sudomotor/edema: edema &/or sweating changes &/or sweating asymmetry, - Motor/trophic: evidence of decreased ROM &/or motor dysfunction (weakness, tremor, dystonia) &/or trophic changes (hair, skin, nails) D. Finally, there is no other Dx that better explains the Ssx & Sx |
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• Complications:
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- Dystonia
- Cognitive executive dysfunction - Adrenal insufficiency - Gastroparesis - IBS |
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• Management:
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- Early treatment may improve prognosis
- Reported cases of spontaneous improvement - Treatment goal: px & discomfort improvement, functional restoration, & disability prevention - PT & exercise improve ROM, function & reduce disability through endorphin release - Px education - NSAIDs / pharmacotherapy - Behavioural therapy (related to depression) - Invasive interventions |
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• Ddx:
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- Arterial insufficiency
- Gillian-Barre s. - Hysteria - Monometric amyotrophy - Multiple sclerosis - Peripheral atherosclerotic disease - Phlebothrombosis - Porphyria - Poliomyelitis - Tabes dorsalis |
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• YELLOW
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• Intro:
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- Common injury in contact sports
- Reflects upper Cx root or peripheral nerve dysfunction injury - Occurs due to over-stretching of upper trunk of brachial plexus or compression of C5/C6 nerve root - Recurrences ar frequent & can result in permanent neurological deficits - Typically graded as Grade I or Grade II nerve injury |
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• Aetiology (risk factors):
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- 1° observed in collision or contact sports (e.g. American football, ice hockey, & rugby)
- Affects 50-65% of collegiate American football players - High recurrence rate requires attention to minimise the problem |
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• Pathophysiology:
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3 primary mechanisms:
- Forceful blow causing depression of shoulder & lateral FX of the neck to the contralateral side, leading to traction of the upper roots of the brachial plexus - A direct blow to supraclavicular fossa or Orb's point causing a percussive injury - Head forced into hyperEXT, ipsilateral side FX towards trauma side → narrowing of intervertebral foramen at Cx spine, nerve root compression (common in high-level athletes) |
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• Clinical presentation:
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- Immediate, acute traumatic onset of px/ burning/paresthesia/pins & needles/weakness
- Typically presents w/ Ssx circumferentially radiating down the arm - Reports recent Hx of trauma to the area - Common in young athletes competing in contact sports - Previous Hx of burners |
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• Physical examination:
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- Shacking of the upper extremity
- Holding upper extremity close to their body - Atrophy or asymmetry in the neck - Shoulder depression - Atrophy of deltoid or supraspinatus - Altered motor patterns when using the shoulder - Palpation: tenderness, muscle spasm, vertebral tenderness - ROM: possible decrease in neck & shoulder mobility - Strength: deltoid (ABD), supraspinatus (ABD - full can), infraspinatus (ER), biceps (elbow FX), pronator teres (forearm pronation), triceps (elbow EXT), & ADD digits minimi (ABD of 5th digit) - Sensation: burning, paresthesia, pins & needles (usually present circumferentially) - Reflexes: triceps & brachioradialis - Special tests: Spurling's test & Tinel test (supraclavicular fossa) |
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• Diagnosis:
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- Usually through clinical examination & past medical Hx
- EMG & NCS: able to determine where the lesion is & its severity - X-rays: indicate or rule out bone injuries |
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• Management:
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- Length determined by severity of injury
- For some recovery may take minutes, for other weeks to months - Commonly reoccur (up to 87%) |
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• Ddx:
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- Necessary to rule out Cx #, dislocation, or spinal cord injury
Alternative/associated Cx injuries inc: - Assessment & management of concussion - Transient quadriplegia - B Ssx - Muscular strain/ligament strain - unlikely to have neurological involvement - Brachial neuritis - insidious onset - Radiculopathy - differences in acute presentation |
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