NMS Q&A Family Medicine

154 NMS Q&A Family MedicineExamination Answers1. The answer is B. C6 supplies sensory fibers to thethumb and motor innervation to the biceps and wristextensors. C5 through C8 compressions all cause neckpain (C4 and T1 do not). C4 pain radiates into the trapeziusand sensory coverage is in the upper shoulder andcape area. C5 radiculopathy radiates into the neck, shoulder,and lateral arm with motor fibers to the deltoid andelbow flexors; the biceps reflex might be depressed andsensory loss in the lateral arm. C7 compression radiatesinto the lateral and middle finger. C8 supplies motion tothe digital flexors triceps and wrist flexors with sensoryinvolvement dorsal forearm and the long finger. C8 compressionradiates to the medial forearm and ulnar digits(4th and 5th). T1 involves motor function of the fingerintrinsic muscles of the hand and sensory involvement ofthe ulnar forearm.2. The answer is D. The Spurling maneuver is axial compressionof the cervical spine (by the examiner pressingdownward on the patient’s head while extending the neckand turning to one side, then the other). The maneuverprecipitates closure of any narrowed foramina in the cervicalspine and causes radicular pain. Eponyms used heremust be forgiven because the listed ones are among manythat inflate the common orthopedic glossary. The Hawkinsmaneuver brings out the pain of rotator cuff impingementthrough eliciting pain with passive inversion of theshoulder while the elbow is flexed 90 degrees and theshoulder forward flexed 90 degrees; Yergason maneuveruncovers biceps weakness by eliciting pain with forcedpronation and supination of the forearm, typically againstthe examiner’s gripped hand; the “empty bucket” signbrings out supraspinatus weakness by showing weaknessin holding the upper extremities at 90 degrees abductionwith the thumbs pointed downward. The Babinski signneeds no introduction.3. The answer is C. L5, among the three most oftenradiculopathy involved lumbar roots in the lumbar area(L4, L% and S1), L5 is the one root that can be implicatedin advanced lumbar pathology and not affect either thequadriceps or the Achilles deep tendon reflexes. L3 is notcommonly involved in radiculopathy and S2 virtuallynever.4. The answer is E. The presence of retrolaryngeal crepitusagainst the vertebral column is a normal finding. In thissituation, it rules against a hematoma resulting from thecervical ligament strain, from which this patient suffers.“Whiplash” by auto accident through rear-ending is themost common cause of neck pain in young people. Thebest way of ruling out vertebral body fracture is, of course,by x-ray. Although retrolaryngeal crepitus disappears inthe presence of a neoplasm in that space, it is not the reasonfor affecting the maneuver in this circumstance. Ludwigangina is cellulitis of the submaxillary and hencesublingual and submandibular spaces. It does not occuron the retrolaryngeal space. This maneuver is not neededto rule against a laryngeal fracture. The latter would bemanifested by crepitation and tenderness in the thyroidcartilage.5. The answer is D. This story is typical of spinal stenosis.The majority of patients are over 60 years of age, althoughthere are uncommon congenital versions. The cause is anycombination of degenerative changes about the lumbarspinal cord: osteophytic spurs, herniated disc(s), or hypertrophiedligamentum flavum. This syndrome may lead toweakness of the proximal lower extremities. Only 25% ofpatients with this syndrome exhibit decreased deep tendonreflexes, and 10% have positive SLR tests. Eighty percentof cases will respond to laminectomy, at least for anindefinite period.6. The answer is E. Sensory deficit of the 4th and 5th fingeris typical of a C8 root syndrome, as are weakness offlexion of the fingers and wrist. The fact that the hypesthesiainvolves all of the ring finger as opposed to only theulnar half favors C8 rather than ulnar nerve compression,as does the intact lumbrical and interosseous musclefunction. Carpal tunnel syndrome causes median nervesymptomatology, that is, sensory deficit of the palmaraspects of the thumb and fingers through the radial halfof the ring finger, as well as dorsal aspects of those fingersdistal to the proximal interphalangeal joints. Carpal tunnelsyndrome also causes a motor deficit consisting ofweakness of thumb–finger apposition. The C6 syndromeis associated with hypesthesia and anesthesia of the palmarand dorsal aspects of the thumb and pointing finger;C7 lesions cause sensory involvement of the middle fingerand the narrow corresponding aspects of the distal ventralforearm and a longer streak of the dorsal forearm.7. The answer is E. Without more chronicity than isfound in this case and in the absence of radicular symptomsand signs, one should treat the case as lumbosacralstrain, with NSAIDs given for a period of about 1 week.Bed rest in a case such as this is to be recommended onlyuntil the patient feels she can begin to move and is not tobe overemphasized. There is no hurry for x-rays and certainlyno hurry for an MRI. It takes 3 or 4 weeks for theNCV test and EMG to show denervation changes in acute