Zahid H. Bajwa, MD. Boston Headache Institute Boston PainCare HMS 2018

Transcription

1 Zahid H. Bajwa, MD Boston Headache Institute Boston PainCare HMS 2018

2 Zahid H. Bajwa, M.D. Director, Boston Headache Institute Director, Clinical Research, Boston PainCare BOARD CERTIFICATION American Board of Psychiatry and Neurology (ABPN Neurology) Board Certified in Pain Medicine (ABA ABPN) American Board of Pain Medicine UCNS Certified in Headache Medicine

3 Disclosures Research Support: Amgen Contributor, UptoDate, Headache and Pain Sections Textbook Principles and Practice of Pain Medicine 2 nd and 3 rd Ed with McGraw Hill Consultant: AstraZeneca, DSI,DepoMed, TEVA, DMSB: Boston Scientific for SCS Consultant: GLG, MEDACorp, McKinsey, Guidepoint

4 Objectives Review of fundamentals of neurological examination, relevant to the examination of patients presenting with complaints of pain. The emphasis will be on examination of the peripheral nervous system. Will also briefly discuss mimics that may be erroneously thought to be neurological in origin.

5 Organization of the Exam The first part consists of general observation of the patient (behaviors, coordination, posture, habitus) Next is the neurological screening (cranial nerves, cerebellar function, brief MSE) Then, the structured peripheral examination.

6 Tools

7 Sensory Testing Patient should be as relaxed as possible. Begin with non noxious modalities, such as light touch, cold, warm, vibration. Always progress from areas of diminished or absent sensation toward areas of greater sensation. Sensory findings taxonomy

8

9 Sensory Testing: Making It Reliable Peripheral sensory exam Subjective Dermatomes (spinal nerves) Peripheral nerves Make PNS Plexus/Plexi Most Cranial Nerves NOT part of CNS Mixed Motor and Sensory Nerves

10 Trigeminal Cervical Tract

11 Trigeminal Nerve

12 Cervical, Occipital Nerves and Vasculature

13 Landmarks: Upper Extremity C5 shoulder patch axillary C6 six shooter radical (thumb) median (index) C7 long finger median C8 small finger ulnar T1 medial brachium med. brach. cutaneous

14 Landmarks: Chest / Abdomen T2 Sternal notch Intercostal T4 Nipple line Intercostal T6 Xiphoid process Intercostal T10 Umbilicus Intercostal L1 Inguinal ligament Ilioinguinal

15 Landmarks: Lower Extremity L2 Anterolateral thigh Ant. Fem. Cutaneous Lat. Fem. Cutaneous L3 Medial knee Obturator L4 Anteromedial leg Saphenous L5 1 st web space Deep peroneal S1 Lateral foot sural

16 Reflex Testing Deep tendon reflex is a misnomer Tendons are abruptly stretched (tapped) as a convenient way of rapidly activating muscle spindle fibers. Muscle stretch reflex is the correct term. Some reflexes can be permanently lost after injury or trauma and may not indicate active pathology.

17 Reflex Grading 0 absent 1+ trace (elicited with reinforcement) 2+ elicited without reinforcement 3+ increased, 1 3 beats clonus, some spread 4+ sustained clonus, other muscles recruited

18 Dorsal Horn of Spinal Cord Substantia Gelatinosa Muscle

19 Reflex Assessment Record the grade for the reflex Comment on speed (brisk, sluggish) Comment on recovery phase, if applicable

20 Pathological Reflexes Higher centers inhibit these reflexes. Injury at a higher level can disinhibit lower reflexes. Caution with patients who are sedated, or emerging from general anesthesia because the general CNS depression can cause transient disinhibition of pathological reflexes. (Great Teaching Opportunity)

21 Pathological Reflexes Babinski s sign: elicited by stroking the lateral aspect of foot, from heel to metatarsal heads. The sign has two parts: great toe extension fanning of remainder of toes Can be enhanced by turning head to opposite side.

22 Pathological Reflexes Hoffmann s sign: elicited by rapid forced flexion of the middle finger distal phalanx, with the wrist in slight extension. Sign looks like the OK sign If symmetrical, especially in anxious patient, not significant. Trömner s variation: tap the palmar aspect of the distal phalanx

23

24 Reflex Testing: Upper Extremity Deltoid C5 Axillary Biceps brachii C6 (C5) Musculocutaneous Brachioradialis C6 (C5) Radial Finger flexors C6 (C7- T1) Median and Ulnar Triceps C7 (C6-8) Radial

25

26 Reflex Testing: Trunk and Perineum Superficial abdominal Intercostals Segmental thoracics Cremasteric L1-2 Ilioinguinal, genitofem. Superficial anal S2-5 Inferior hemorrhoidal

27 Reflex Testing: Lower Extremity Patellar L4 (L2-3) Femoral Tibialis Anterior L4 (L4-S1) Deep peroneal Medial Hamstring L5 (L4-S2) Tibial Portion of Sciatic Achilles (triceps surae) S1 (L5-S2) Posterior tibial Plantar S1 (L4-S2) Posterior tibial

28

29 Muscle Grading 0 no contraction visible 1 flicker or trace of contraction 2 full ROM with gravity eliminated 3 full ROM against gravity only 4 full ROM against gravity + some resistance 5 full ROM against gravity + full resistance

30 Muscle Testing: Upper Extremity Deltoid C5 (C6) Axillary Biceps Brachii C6 (C5) Musculocutaneous Brachioradialis C6 (C5) Radial Flex. Carpi rad. C6-7 Median Triceps C7 (C6-8) Radial Flex. Dig. Superfic. C8 (C7-T1) Median Abd. Dig. Minimi C8-T1 Ulnar First dorsal interos. T1 (C8) Ulnar

31

32 Muscle Testing: Lower Extremity Iliacus & psoas L2 (L1-3) Psoas n. and femoral Thigh adductors L2-3 (L4) Obturator, some sciatic Quadriceps femoris L4 (L2-4) Femoral Gluteus medius L4-5 (S1) Superior gluteal Tibialis anterior L4 (L4-S1) Deep peroneal Ext. hallucis longus L5 (S1) Deep peroneal Gastroc / soleus S1-2 Tibial Peroneus longus S1 (L4-S1) Sup. peroneal

33

34

35 Modified Schöber s Measurement A helpful way to assess lumbar ROM that attempts to isolate lumbar segments from hip motion. With neutral spine, from intercristal line mark up 10 cm and down 5 cm Measure between two marks in flexion Normal is 20 cm

36

37 Nerve Stress Maneuvers Can be either impingement or stretch Must be done correctly (frequently not) Sciatic nerve stretch Cervical roots impingement

38 Straight Leg Raising Must be done totally passively Less than 30 degrees, no significant tension About 70 degrees, maximum tension Patient must complain of sciatica, not back pain, hamstring tightness or hip pain Bragard s sign: active dorsiflexion of foot Ask questions nondirectively

39

40 Crossed SLR Do the SLR maneuver on the side opposite the complaint Root pathology may cause symptoms of sciatica down the extremity of interest SLR on Right causing shooting pain down the back of the extremity below the knee on the Left

41 Spurling s sign Patient s head and neck are extended Laterally flexed to the affected side Some compression on head by examiner Positive sign is pain down the affected upper extremity False positives: myofascial pain, TOS, anticipatory anxiety causing tension

42

43 Hip Pathology Patrick s sign (figure four, Fabere) A hard, nonmuscular, stop of ROM is suggestive of hip disease Hip or back pain with slight force of maneuver is suggestive of hip disease

44

45

46 Conclusion Any physician who is practicing the primary specialty of pain medicine or a pain management subspecialty must be able to perform and record a neurological examination to establish or rule out a diagnosis, to assess procedure outcomes and to formulate a comprehensive treatment plan. This applies to primary care folks, too!

47 With Graphic Pain and other somatic symptoms occur as a continuum rather than as yes or no All of the defining features of somatic syndromes such as FM, IBS, etc. occur as a % of Population continuum 0 Tenderness