NMS Q&A Family Medicine

Musculoskeletal Problems of the Neck and Back 155compression radiculopathies, even when there are positivesymptoms and signs of radiculopathy such as sensoryor motor changes (e.g., changes in deep tendon reflexes,dermotomal numbness, and weakness of heel or toe walking).Physical therapy modalities would be employed onlyafter more conservative measures fail over a period of atleast 2 weeks.8. The answer is A. This patient is in the age group forbreast cancer; there are no symptoms or signs of radiculopathy,and there are no signs of any musculoskeletal conditionwhatever. Completion of the physical examinationis, in this case, for the specific purpose of searching for abreast lesion (after review of her family history for breastcancer and inquiry as to whether she has had timely mammogramsas recommended for the patient 40 years of ageand older). Although the MRI could await the results ofthe plain x-rays, it might as well be ordered immediately,along with alkaline phosphatase testing. The latter is sensitivefor bone metastases. Electrical studies are not indicatedin the absence of suggestions of radiculopathy.NSAIDs may be helpful but are not relevant to the mainthrust of ruling out cancer.9. The answer is A. Hyperextension of neck, commonlyreferred to as whiplash injury. The hyperextension is mosttypically produced by the victim’s being in a motor vehiclethat is rear-ended by another vehicle. Cervical vertebralbody subluxation or fracture would cause most certainlyneurological symptoms. The greatest risk for either ofthese injuries would be a sharp hyperextension such asoccurs with a sharp blow to the head from the front asopposed to the hyperextension that occurs with the whiplashmechanism. Extreme rotation of the neck also isfraught with serious sequelae but does not commonlyoccur in the whiplash mechanism. Contusion of the neckitself requires a direct blow to the soft tissues of the neck,something that would not occur in a rear-end strike unlessthere were objects loose in the cab of the car. In this andany of the alternative examples given, the pain would notbe expected to be delayed as it is in the cervical ligamentstrain employed in the whiplash mechanism.10. The answer is C. The affected cervical nerve root isC6. This is a result of a herniation of C6 to C7 or, lessoften and certainly more possible in a person over the ageof 50 years, an osteophytic spur. The classic picture of aC6 lesion shows sensory symptoms of the radial forearm,the index finger, and thumb, and motor involvement ofthe biceps and wrist extension. Patients are treated conservativelyat first, by NSAIDs, warm applications, massage,physical therapy, and possibly cervical traction with5 to 15 lb (2.3 to 6.8 kg).11. The answer is D. An MRI is useful as a diagnostic toolfor herniated discs but should rarely be used for neck (orback) pain in the absence of radicular symptoms becausethe test is too sensitive. The more sensitive a test’s criteriafor positivity, the less specific. Many patients will havepositive findings of intervertebral discs showing discernibledegrees of herniation that will never become surgicalcases. Thus, consulting a neurosurgeon implies not onlyradicular symptoms (radiation of pain in the distributionof the involved root, sensory symptoms in the appropriatedermatomes, motor symptoms appropriate to theforegoing findings, or any combination thereof) but alsothe possibility of the case becoming appropriate for surgicalcorrection. Electrical studies are helpful for pinpointingsymptoms but do not generally become positive untilthe symptoms have been present for 3 weeks. Plain films,although included virtually always in evaluation of neckpain, tend to be too sensitive and not specific enough.Sedimentation rate is useful in evaluating a patient forinflammatory arthritis, which would not be considered inthis case because of the rapidity of onset and the precipitatingactivity.12. The answer is A. This is an example of ankylosingspondylitis. These patients are HLA B-27 positive in 85%of cases. Men are affected more often, more severely, andearlier than women. Peripheral joint involvement occurstransiently in about 50% of cases, and hips, shoulders,and knees permanently in about 25%. Involvement is notsymmetrical and does not manifest erosion and demineralizationas occurs in rheumatoid arthritis.13. The answer is A. Hand and arm atrophy are commonadvanced signs of herniated nuclear pulposus of a cervicaldisc. It takes 3 or 4 weeks for the EMG to show denervationchanges in acute compression radiculopathies. TheSpurling test is positive when there is aggravation of thepatient’s radicular pain or sensory changes when the neckis rotated toward the side of the pain (while in extension)with pressure applied to the head. Although this test ishighly specific, it is poorly sensitive. Patients do not usuallyreport a history of recent blunt trauma to the neck,but they may report noticing their symptoms after activitiesthat stress the cervical musculature, including sneezingor violent maneuvers of snuffling during upperrespiratory infections. Numbness of the 5th and themedial half of the ring finger are typical symptoms ofulnar nerve dysfunction. Although radiculopathy involvingC8 causes hypesthesia of the 4th and 5th fingers, thesyndrome is dermotomal and does not spare the lateralhalf of the ring finger.