Approach to neck pain


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Approach to neck pain

  1. 1. APPROACH TO NECK PAIN Dr. Yassir Hussain.P
  2. 2. In General  Difficult to arrive at an anatomical diagnosis  Most important is to be able to recognize a serious pain state  Differentiate neck pain due to common diseases from neck pain due to local pathology
  3. 3. EPIDEMIOLOGY  Very common; 2 out of 3 people experience neck pain at some point in life  High among the working aged populace  Incidence in general populace is 10-20%  25-40% complain of associated radiation to upper extremity
  4. 4. Epidemiology..  In the population>45 yrs old >50% have neck pain/stiffness  Incidence is higher in women & 30-50 year old adults  Whiplash injuries are a common cause
  5. 5. RTA & Whiplash  62% of RTA victims have whiplash  33-66% develop symptoms within 24 hours  30-42% have continued intermittent pain at 1 year  6% have continuous pain at 1 year  28% have chronic pain
  6. 6. CLASSIFICATION  Local  Acute- <12 weeks  Chronic- >12 weeks  Radiating  Whiplash
  7. 7. Alternative classification  Arising from the muscles, ligaments & joints of the neck  Arising from the cervical nerve roots or the spinal cord
  9. 9. Examination  History  Onset-Acute or Insidious?  Site of pain  Character  Radiation  Radiation- Dermatomal or diffuse?  Aggravating factors and relieving factors  Prior trauma
  10. 10. History..  Joint pain?  Prior general diseases?  General symptoms- fever ,weight loss etc.  Symptoms of neurological complications- weakness, parasthesiae, gait disorders, vertigo, visual disturbances
  11. 11. Examination..  Inspection  Supraclavicular fossae- asymmetry?  sternocliedomastoid-spasm/swelling  Palpation  Midline tenderness posteriorly- spondylosis/infections  Paraspinal tenderness- swellings/muscle spasm
  12. 12. Examination..  Anterior neck-supraclavicular fossae- swellings/cervical ribs  Thyriod?/ salivary glands?  LNE?  Temporal artery tenderness/induration?
  13. 13. Examination..  Movements  Flexion  Extension  Lateral flexion  Rotation  Check for active and passive motion  The shoulders should be horizontal while testing for movements  Normally the chin can touch the chest
  14. 14. Examination..  If lateral flexion cannot be carried out without forward flexion this shows involvement of the first two joints  When checking for rotation the shoulder should be restrained by the physician  1/3 rd of rotation occurs at the first two joints  The nose & forehead should be in the horizontal plane on full extension  1/5 th of flexion-extension & lateral rotation occur at the first two joints.
  15. 15. Examination..  When checking for passive motion place the patient erect on a stool. standing behind the patient the left hand stabilizes the shoulder blades in the horizontal plane while the left test for extension and rotation starting from the neutral.  When testing for flexion the hands are reversed.
  16. 16. Normal range of motion  Flexion :80°  Extension :50°  Lateral flexion :45°  Rotation :80° to either side
  17. 17. Examination..  If there is pain try to differentiate whether pain arises from the neck or shoulder or both.  Reflex muscle spasm due to pain will cause limitation of movements but this can be overcome passively  If real limitation of movements persists it indicates structural damage within the corresponding joints.
  18. 18. Examination..  Mechanical problems usually cause asymmetric limitation of movement  Inflammatory/ Neoplastic disorders on the other hand are widespread and more or less symmetric ; hence pain & movement restriction will also be symmetric
  19. 19. Movements..
  20. 20. Movements..
  22. 22. Examination..  Specific tests  C1-C7 neurological exam & further as req.  Crepitus  Cervical rib  Radiculopathy  Myelopathy
  23. 23. Neurological exam  C1-C4 involvement will show no motor weakness or reflex changes clinically C5 C6 C7 C8 Sensory Lateral arm Thumb Middle finger Little finger Motor Deltoid Wrst extensors Tricep Finger flexion Disc C4-C5 C5-C6 C6-C7 C7-T1 Reflex Bicep Brachioradialis Tricep
  24. 24. Examination..  It is possible to test the sensory supply of C2-C4  Neck flexion/lateral flexion are by C2,C3 & spinal accessory  Neck extension is by C3,C4,spinal accessory & the posterior rami of spinal nrves  Trapezius reflex is mediated by C3,C4
  25. 25. Specific..  Crepitus  Spread both hands on either side of the neck and ask patient to flex and extend the neck.  Facet joint crepitus-a common finding in spondylosis is felt  If in doubt auscultate
  26. 26. Crepitus
  27. 27. Specific..  Cervical rib  Look for vascular deficits in the upper limb  Adsons test-patient takes a deep breath and turns his head toward the side of the lesion; watch for radial pulse obliteration or decrease  Auscultate over supraclavicular area to check for murmur of subclavian artery compression
  28. 28. Specific..  Radiculopathy  Lateral stretch test  Cervical compression test/anvil test/Spurlings test  Distraction test  Shoulder abduction relief test  Tinels sign  Upper limb tension tests
  29. 29. Radiculopathy..  Lateral stretch test  Stretching of the neck in the opposite direction will elicit pain along the nerve root distribution
  30. 30. Contd..  Spurlings test  Sit the patient on a stool with head in neutral position & with the head in 45 degree rotation to either side with the head tilted toward the ceiling.  In each of these three positions apply brisk compression in the line of the spine standing behind the patient.  If the patient suffers from foraminal stenosis of any cause there will be root pain along the distribution of the concerned root
  31. 31. Spurlings test
  32. 32. Radiculopathy..  Distraction test  Passively elevating the head in the neutral position by holding it at the occiput and chin will relieve symptoms
  33. 33. Anvil & Distraction test
  34. 34. Radiculopathy..  Shoulder abduction relief test  Significant relief of pain with shoulder abduction  Seen in soft cervical disk prolapse  Negative in radiculopathy due to spondylosis
  35. 35. Radiculopathy..  Tinels sign  In radiculopathy direct palpation or percussion over the exiting nerve root may provoke the patients typical pain  If it is found to be positive more laterally ,such as over the supraclavicular fossae then the diagnosis should be questioned
  36. 36. Upper limb tension test 1
  37. 37. ULTT1
  38. 38. ULTT1
  39. 39. Upper limb tension test 2
  40. 40. ULTT2
  41. 41. ULTT2
  42. 42. Upper limb tension test 3
  43. 43. Upper limb tension test 4
  44. 44. Radiculopathy..  Radiculopathy may be associated with myelopathy  Can involve one or multiple roots  Findings may overlap due to intraneural intersegmental connections of sensory nerve roots
  45. 45. Radiculopathy..  Neurological findings suggestive of radiculopathy besides the above signs are  Pain/ parasthesiae aggravated by coughing/sneezing  Parasthesiae along nerve root distribution  Pain & tenderness along muscles of the involved myotome  Weakness of said muscles  Depressed reflexes corresponding to the involved root  Basically LMN signs.
  46. 46. Specific..  Myelopathy  LMN signs in the upper limbs at the level of compression (flaccid paralysis, muscle atrophy, absent reflexes)  UMN signs below the level of the lesion, mainly evident in the lower limbs. (hypertonicity, hyperreflexia, clonus, Babinskis sign)  Sensory deficit is non dermatomal involving large areas e.g.-whole arm/forearm/wrist  Bladder involvement may be present  Funicular pain (burning pain)
  47. 47. Other signs of myelopathy  Hoffman's test/dynamic Hoffmann's test  Lhermittes sign  Inverted supinator jerk/inverted radial reflex  Clonus  Myelopathy hand  Gait abnormalities such as ataxic broad based shuffling gait
  48. 48. Myelopathy..  Hoffmann's test  Rapidly extend the distal phalanx of the middle finger by flicking its pulp  Positive if there is flexing of the IP joints of the index & thumb  Dynamic Hoffmann's test  Repeat while the patient flexes & extends the neck which facilitates the response
  49. 49. Myelopathy..  Lhermittes test  Flexion or extension produces electric shock like sensations , particularly in the legs.  Inverted supinator jerk  While eliciting the brachioradialis jerk instead of brachioradialis contraction we get flexion of the fingers of the hand  Highly specific for lesion at C5
  50. 50. Myelopathy..  Myelopathy hand  Kinetic  Inability to flex & extend the fingers rapidly  Time over 10 seconds  Usually in excess of 20 cycles  Postural  Deficient adduction & often extension of the ulnar 1-3 fingers
  51. 51. Myelopathy..  In the mildest cases when the fingers are extended the little finger lies slightly in abduction; even if adduction is possible it cannot be held for long. abduction is normal (finger escape sign)  If severe the little, ring & sometimes the middle finger may abduct and/or the same fingers may flex & loose their power of extension.  Myelopathy is most common at C5 ,first affecting deltoid & infraspinatus
  52. 52. Myelopathy..  Motor weakness when present is asymmetric & usually affects multiple levels  Vibration & position sense are often reduced  Babinskis sign becomes positive only late in the disease
  53. 53. Myelopathy..  Any lesion which compresses the cord can cause myelopathy but in particular consider  Canal stenosis  Spondylosis  Cervical kyphosis  Old dens # non union  Investigated best by CT myelography, MRI or dynamic MRI
  54. 54. Anatomy of compression  Anterior compression-IVDP/osteophytes  Anterolateral compression-joints of Luschka  Lateral compression- facet joints  Posterior compression- ligamentum flavum
  55. 55. How to differentiate the source of neck pain Pain from joints ligaments/muscles  c/o pain & stiffness  Deep, dull aching & often episodic pain  h/o excessive/unaccustom ed activity or of sustaining an awkward posture Pain from nerve roots or the spinal cord  c/o root pain  Sharp, intense often burning pain  Radiates to trapezial, interscapular areas or down the arm
  56. 56. Differentiation Contd..  No h/o injury  Localized asymmetric pain  Upper cervical pain is referred to the head, lower cervical to the arm  Aggravated by movement, relieved by rest  Numbness & motor weakness in a myotomal distribution  Headache may occur with upper root involvement  Symptoms aggravated by neck hyperextension.
  57. 57. When to suspect serious disease  Unrelenting symptoms and pain radiating to both hands  Systemic causes such as  Ankylosing spondylitis  Polymyalgia  Malignancy/myeloma/metastasis  Osteomyelitis/tuberculosis  Myelopathy  Progressively increasing pain c.f episodic
  58. 58. Is the patient faking?  Non-organic signs of Waddell  Nonanatomic tenderness  Simulation sign  Distraction sign  Regional motor or sensory disturbance  Overreaction
  59. 59. Waddell's signs  Their interpretation depends on the experience of the physician with a wide range of patients  The signs are significant when more than one are present in the same patient  The most sensitive sign is overreaction
  60. 60. Nonanatomic tenderness  Said to be present when the patient complains of pain with extremely light touch or tenderness whose distribution does not conform to the distribution of known anatomic structures  Verified by palpating areas that are not usually tender  CRPS is an exception
  61. 61. Simulation sign  Positive under two circumstances  Patient c/o pain along the whole length of spine or in the lower back in response to spurlings test  Patient c/o pain when the rotation simulation maneuver is done i.e head & shoulders are rotated in a manner coplanar with the pelvis
  62. 62. Distraction sign  Pertinent only in case of back pain  Patient c/o pain in the SLR test but fails to do so when the knee is extended from the seated position
  63. 63. Regional motor/sensory disturbance  Regional sensory disturbance exists when there is sensory disturbance in a nonanatomic distribution such as glove & stocking distribution  Regional motor disturbance is suspected if there is diffuse weakness in multiple muscle groups/in the whole limb etc or if the examiner feels that the patients muscles give way in an unphysiological manner during strength testing
  64. 64. Overreaction  Present when the patient reacts physically or verbally in an inappropriately theatrical manner in response to light palpation or gentle methods of examination
  65. 65. INVESTIGATIONS  Plain x rays  Stress x rays  CT  MRI  Myelography  Nerve conduction studies/electromyography  Nerve blocks  Discography
  66. 66. Investigations..  As required  ECG  Blood R/E  LFT  S.electrophoresis
  67. 67. Investigations..  X rays AP, lateral, oblique  More useful when acute severe injury is suspected  Tumors, infections are other instances  Oblique view shows foramina  Stress x rays  Used to demonstrate spinal instability in patients without neurological deficits whose plain films show no findings
  68. 68. Investigations..  CT  Detects # missed by x rays  Useful in assessing spinal canal/foramina  MRI  Helps in diagnosing disc rupture/herniation  Intraspinal soft tissue processes e.g.- intra/epidural abscesses, hematomas, Intraspinal tumors
  69. 69. Investigations..  Degenerative disc changes present in 25% of asymptomatic adults under 40 yrs,60% of those over 40 years & 70% of those over 70 yrs
  70. 70. Investigations..  Myelography/contrast CT  To study the relation between bony & neural structures for pre-op planning  Nerve blocks  Facet block/cervical sympathetic blocks/trigger point blocks etc help to diagnose the site of lesion as well as being therapeutic occasionally
  71. 71. Investigations..  Discography  May help in identifying the affected disc  May identify disc rupture missed by MRI  However the risks generally outweigh the benefits.  Nerve conduction studies/electromyography  Help confirm radiculopathy  Only way to diagnose C3,C4 radiculopathy is EMG
  72. 72. Differential diagnosis  “Tension neck”  Torticollis  Fibromyalgia  Myofascial pain syndromes  Cervical spondylosis  Cervical IVDP  Whiplash (#, dislocations, ligamental injuries)
  73. 73. Dd Contd..  Infections-TB, Osteomyelitis, epidural abscess  Tumors-primary & metastatic  Myelopathy  Cervical stenosis  OA of facet joints/joints of Luschka  Brachial plexus pathologies
  74. 74. Dd Contd..  Thoracic outlet syndrome  CRPS  Herpes Zoster  Inflammatory pathology e.g.-Rheumatoid arthritis, Ankylosing spondylitis  Syringomyelia  Transverse myelitis
  75. 75. Dd Contd..  Meningism  Severe arterial hypertension (suboccipital pain)  Epidural heamorrhage  CVJ/vertebral anomalies  Myopathies  Pain from shoulder joint/rotator cuff
  76. 76. Dd Contd..  Pain from the upper limb e.g.-lat. Epicondylitis, CTS  angina pectoris/MI- if risk factors/associated with exertion, ”cervical angina syndrome”  Abdominal irritation e.g.-cholecystopathic pain
  77. 77. Nonspecific neck and shoulder pain  Torticollis  “Tension neck”  Fibromyalgia  Myofascial pain syndromes
  78. 78. Torticollis (Wry neck)  Rotational deformity of upper cervical spine causing turning & tilting of the head  Head tilted to involved side & chin to opposite side  Due to wide number of causes  Congenital  Neurologic  Inflammatory  Traumatic
  79. 79. Torticollis..  Congenital may be due muscular wry neck or due to anomalies of upper cervical spine like klippel-feil syndrome, basilar impression, odontoid anoimalies, Atlanto- occipital fusion etc  Neurologic abnormalities like ocular dysfunction, syrigomyelia,s.cord/cerebellar tumors can lead to torticollis
  80. 80. Torticollis..  Inflammation can cause torticollis such as cervical lymphadenitis, rotatory subluxation of childhood  Trauma of any sort to upper spine especially C1-C2 is another cause
  81. 81. Tension neck  Patient c/o neck pain usually in the suboccipital & posterior aspects  Muscle tenderness will be present  H/o stress/holding head in abnormal position/unaccustomed work/faulty posture will be present  Pain may radiate to scalp due to irritation of superior occipital nerve
  82. 82. Fibromyalgia  Clinical syndrome charachterized by diffuse vague pain, extreme fatigue, stiffness, tender points, sleep disturbance  Thought to be due to disturbance in stage 4 NREM sleep  Diagnosed by  h/o widespread pain especially shoulder/pelvic girdle  Pain at 11 out of 18 tender points on 4 kg force
  83. 83. Fibromyalgia tender points
  84. 84. Fibromyalgia Contd..  Pain in muscles & joints  Worst in the morning   muscle tone, breakaway weakness, livedo reticularis may be present  Joints are not tender.  Skin fold roll test-rolling of skin fold at T12 level from below upwards will cause severe pain
  85. 85. Myofascial pain syndrome  Diagnosis is made when on examination we find trigger points in the affected muscles  Trigger points are tender knotted points that on palpation will cause pain at a different site  Infiltration with lignocaine is useful both as a diagnostic & therapeutic test
  86. 86. Cervical Spondylosis  Actually is a combination of degenerative & herniated IVDP  Also called osteoarthritis, osteoarthrosis, chronic herniated disk, chondroma, spur formation, osteophytosis  Seen in 75% of those .65yrs old  May present as neck pain & myelopathy ,Neck pain & radiculopathy or progressive myelopathy
  87. 87. Spondylosis..  Radiculopathy due to osteophytes  Myelopathy due to stenosis, osteophytes & PLL calcification  Most commonly affects C5-C6,C6-C7 & C4- C5  Occiput to C3 involvement is uncommon  Vertebral artery maybe involved in the transverse foramen
  88. 88. Spondylosis..  Arthritis of facet joints or joints of Luschka can cause pain  Disk degeneration leads to IVDP  Cervical Spondylosis without pain is similar to Multiple sclerosis (involvement above f.magnum), Amyotrophic lateral sclerosis (no sensory changes, mixed UMN & LMN of all limbs), Syringomyelia and spinal cord tumor
  89. 89. Spondylosis..  When there is cervical IVDP pain is a poor guide to localization, sensory/motor loss & reflex changes are a better guide  1/4th have sensory loss  1/3rd have subjective weakness  3/4th have objective weakness
  90. 90. Cervical canal stenosis  Risk of spinal cord injury is greater if trauma occurs  Torg ratio  Diameter of canal: width of cervical body (AP)  <0.8 indicates stenosis  Pavlov ratio  Canal: vertebral body width  Normally 1 ,<0.85 stenosis,<0.8 high risk for later injury-it also indicates congenital stenosis  Absolute stenosis-AP diameter<10mm  Relative stenosis-AP diameter10-13 mm (normal is 17)
  91. 91. Spinal cord lesions  Produce deep, constant, progressive pain not  by coughing/sneezing  Spinal epidural abscess starts as localized ,boring pain which leads to muscle spasm & cervical rigidity rapidly progressing to cord progression. MRI is the investigation of choice
  92. 92. Cord lesions..  Spinal epidural hemorrhage presents as sudden severe pain with radicular component and respiratory distress.50% have motor symptoms in 12 hours.15% are due to trauma. Investigated best by MRI/CT
  93. 93. Herpes zoster  Usually affects 1 root occasionally 2-3 roots  Usually vesicles appear first then pain  Severe lancinating pain  Involves only one side of the body  In C2 involvement the pain appears first as the vesicles are hidden by the hair/ear  Motor weakness in 60%
  94. 94. Syringomyelia  Due to disturbed hydrodynamics of spinal fluid resulting in central syrinx formation  More common in thoracic than cervical area  Maybe idiopathic, traumatic or associated with spinal cord tumor  Idiopathic form associated with Arnold – Chiari malformations
  95. 95. Syringomyelia..  Occurs in 1-3 % of spine trauma  Presents as radicular pain, spasticity, dissociative anaesthesia in the form of “cape” sensory loss, LMN signs at the level of the syrinx (usually the arms)  If ir enlarges then UMN LL sings develop  25-80% have left thoracic scoliosis  MRI is investigation of choice
  96. 96. Brachial plexus pathology  Two types of brachial plexus pathology cause neck pain  Preganglionic plexus injuries  Brachial neuritis
  97. 97. Preganglionic brachial plexus lesions  Can cause severe pain along the neck ,shoulder & arm with an anaesthetic limb when the upper plexus is involved  Look for features of C5, C6 involvement by examining myotomes and dermatomes.  C5 myotome is mainly deltoid, dermatome is lower deltoid  C6 myotome is tested by testing for supination/ pronation, dermatome is index finger
  98. 98. Preganglionic..  Reflexes affected are biceps & brachioradialis  Preganglionic nature is diagnosed by  Nerve to serratus anterior involvement  Dorsal scapular nerve involvement (Levator scapulae & rhomboids)  Long tracts of spinal cord involvement  Retention of sensory conduction in the presence of sensory loss
  99. 99. Preganglionic..  Histamine test  Anaesthesia above the clavicle  Elevated hemidaiphragm (in CXR)  CT myelography
  100. 100. Preganglionic..  In the histamine test axon reflex i.e. flare will be absent only in post ganglionic lesions  EMG will show denervating potentials in the segmental paraspinal muscles supplied by the posterior primary rami  NCS will show retained motor & absent sensory conduction  Sensory action potentials will be present
  101. 101. Preganglionic..  Sensory evoked potentials will also be present  CT myelography- done after 6-12 weeks to allow dissolution of blood clots will show pseudomeningocoele/absence of nerve root shadow at lesion site
  102. 102.  Other suggestive features are  Involvement of all 5 roots  Severe pain in anaesthetic arm  Posterior triangle bruising and supraclavicular sensory loss  Transverse process fracture  Horners syndrome
  103. 103. Brachial neuritis  Also called brachial plexitis/ plexopathy /neuralgic amyotrophy/parsonage-turner syndrome  Presents abruptly in a normal individual  Usually a male in his 3-7th decade  1/3rd it is bilateral  Severe neck/shoulder/arm/scapular pain that may last hours to weeks
  104. 104. Brachial..  Followed by severe muscle weakness and wasting  Less of sensory changes  Maybe a h/o preceding infection/immunization  Recovers over months  EMG & NCS help in c.f from root lesion
  105. 105. Thoracic outlet syndrome  Due to compression of neurovascular structures at the thoracic outlet bounded by the 1st rib, clavicle & scalene muscles  3 types  True neurogenic TOS  Upper cord compression  Lower cord compression  Vascular TOS  Disputed TOS
  106. 106. TOS..  Of these upper cord compression neurogenic TOS can present as neck/face/shoulder/ arm pain with features of C5,C6,C7 involvement  Associated maybe features of ischaemia/ embolization/venous compression  Usually occurs in young to middle aged females  Tests are  Adsons test  Military test  Hyperabduction manouver  EAST (Roos test)
  107. 107. TOS Contd..  Adsons, military & hyperabduction tests are for the vascular component ,EAST is what concerns us  The patient is asked to slowly open and close his hands while keeping the arm abducted, externally rotated and flexed to 90 degrees at the elbow for 3 minutes  Normal patients experience only fatigue, neurogenic TOS patients experience pain & parasthesiae
  108. 108. TOS Contd..  Investigated by  X ray cervical spine  EMG/NCS – which show prolonged conduction times. Somatosensory evoked potentials can be used to locate site of lesion
  109. 109. Whiplash  Two types  Hyperextension injury/acceleration injury/rear end collision injury  Hyperflexion injury/decceleration injury/front end collision injury
  110. 110. Hyperextension injury mechanism  Rear impact neck hyperextension  protective flexor muscle spasm which unfortunately acts as a compressive force along the cervical spine resulting in compressive hyperflexion
  111. 111. Hyperflexion injury mechanism  Front end collision hyperflexion  protective extensor muscle spasm hyperextension
  112. 112. NEWEST CONCEPT
  113. 113. Findings in whiplash radicular damage  Neck rigidity & limited extension  Limited rotation to side of injury  Pain & parasthesiae aggravated by cough/sneeze  Tenderness over affected vertebrae  Parasthesiae along affected nerve roots  Pain and tenderness along affected myotome
  114. 114. Findings..  Weakness of supplied muscles  Depressed reflexes of corresponding root
  115. 115. INJURIES TO C1, C2
  116. 116. Facet dislocation  If on cervical spine lateral view the dislocation of the vertebral body is ,1/2 of its AP diameter it is U/L facet dislocation  If dislocation is >1/2 it is B/L facet dislocation  Facet injury is responsible for pain in 50- 60% cases of whiplash  Post-traumatic headaches in 33%  Usually at C2-C3 & C5-C6 levels
  117. 117. Sympathetic nervous system injury  Called Barre-Lieou syndrome  Injury can occur at  Posterior cervical sympathetics  Sensory elements of C1,C2  Irritation of nerve root at neuroforamen  Compression of vertebral artery  Encroachment of basilar veins
  118. 118. Barre-Lieou syndrome  Characterized by  Aural-tinnitus/deafness/postural dizziness  Ocular-blurring/retro bulbar pain/pupil dilatation on turning to affected side  Other-corneal hypoesthesia/ miosis/ rhinnorrhea/ sweating/ lacrimation/ photophobia/ cranial nerve dysfunction/ hoarseness/ aphonia/ upper extremity dysesthesia
  119. 119. Barre lieou..  This is because the cervical sympathetics contribute to carotid plexus, brachial plexus, cardiac plexus, aortic plexus & phrenic plexus
  120. 120. Central cord syndrome  h/o rear end collision in an elderly subject  No head collision/LOC  Sudden hyperextension  Numbness of whole trunk and extremity  Inability to move arms/legs  Inability to void
  121. 121. Central cord..  O/E  Motor weakness of UL>LL  Sensory loss below level of lesion  Bladder dysfunction   Thought to be due to  Contusion of cord  Transient ischaemic damage to cord
  122. 122. Central cord..  Cord contusion is due to squeezing of the cord between hypertrophic spur anteriorly & ligamentum flavum posteriorly  Ischaemia is thought to be due to vertebral artery being affected at  Atlanto-axial joint  Atlanto-occipital joint  # dislocation above c6
  123. 123. Central cord..  In contusion there is both motor & sensory loss  In vascular injury usually sensory loss is minimal/absent with mainly motor loss
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