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Musculoskeletal Condition Mimicking Spinal Disorder: Upper Extremity

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Musculoskeletal Condition Mimicking Spinal Disorder: Upper Extremity 2015 SNU Orthopedic Update (Ⅰ) Musculoskeletal condition mimicking spinal disorder: Upper extremity 서울대병원 정형외과 김지형 Musculoskeletal conditions mimicking cervical lesion . Shoulder: Impingement syndrome, rotator cuff tendinopathy, frozen shoulder . Elbow: Lateral epicondylitis, medial epicondylitis . Hand and wrist: de Quervain’s disease, trigger thumb, trigger finger Differential diagnosis . Peripheral nerve entrapments Double crush syndrome Cervical radiculopathy . Pain, paresthesia, and motor weakness . Only 55% of patients with a nerve root compression had pain in a strictly radicular pattern. Henderson et al, 1983 . Motor deficits are present in 60% to 70% of patients with radiculopathy and that roughly 70% have reflex changes. Lunsford et al., 1980 Cervical radiculopathy . Spurling sign: neck hyperextension, head tilting toward the affected side . Sensitivity (30%), specificity (93%) for cervical radiculopathy . It helps to confirm a cervical radiculopathy. Pain relief with a slight amount of neck flexion . Valsalva Maneuver . Shoulder abduction relief sign Davidson et al., 1981 Differential diagnosis of cervical radiculopathy Upper cervical lesion . Radiculopathies above C2: extremely rare, jaw pain and occipital headaches, no motor deficit . C3 radiculopathy: disk disease at C2‐3, not common, headache and pain along the posterior aspect of the neck that extends to the posterior occipital region and occasionally to the ear . C4 radiculopathy: neck and trapezial pain, no motor deficits, numbness and pain at the base of the neck that extends to the shoulder and scapular region. Classic patterns of cervical radiculopathy Compression of the C5 nerve root . Pain and/or numbness in an “epaulet” pattern (superior aspect of the shoulder, lateral aspect of the upper arm) . Weakness of deltoid motor function . DDx with shoulder lesion: Impingement signs or pain with passive shoulder motion . Depression of the biceps reflex is an inconsistent finding. C6 involvement . Pain or sensory abnormality extending from the neck to the biceps region, down the lateral aspect of the forearm to the dorsal surface of the hand, between the thumb and index finger. Depression of brachioradialis reflex, weakness of wrist extensor BR (C5, C6), ECRL (C6, C7) . Involvements of infraspinatus, serratus anterior, triceps, supinator, and extensor pollicis. DDx: pronator syndrome, AIN entrapment, CTS C7 involvement . Pain and sensory abnormalities extend down the posterior aspect of the arm and the posterolateral aspect of the forearm and typically involve the middle finger. Absence of the triceps reflex, triceps weakness . Involved muscle groups wrist flexors: FCR (C6,7), PL (C7,8), FCU(C7,8, T1) wrist pronators: PT (C6,7), PQ (C7,8) finger extensors: EDC (C7,8), EDM(C7,8), EPL(C7,8), EIP (C7,8) latissimus dorsi: thoracodorsal nerve (C6,7,8) . DDx: pronator syndrome, AIN entrapment, CTS Pronator teres syndrome vs C6‐7 radiculopathy . Sensory involvement of the radial three and a half fingers and median nerve innervated muscles. Wrist extensors (C6) and triceps (C7) are saved. Forearm compression test, forearm resisted pronation test, Middle finger FDS test AIN syndrome . Pain in the proximal forearm . Weakness of the FPL, pronator quadratus, FDP (2, 3) . FDP (3) may not always be exclusively innervated by the median nerve. No sensory loss . DDx: Parsonage‐Turner syndrome (history of severe pain for several weeks, following a viral disease) . Physical examinations: OK sign, test of tip‐to‐tip pinch Carpal tunnel syndrome . It mimics a C6‐C7 radiculopathy from a sensory standpoint. Triceps (C7) and wrist extensor (C6) muscles are saved. Thenar motor weakness (DDxT1 radiculopathy; hypothenar, ulnar nerve innervated intrinsic muscles.) . Painful numbness occurs especially at night. In the morning, many patients try to shake the hand awake. Tinel sign (at wrist), weakness of palmar thumb abduction Among 362 patients, cervical arthritis was found in 253 patients (70%), and C5‐C6 arthritis was the most common site. Radial nerve compression . Radial tunnel syndrome, PIN syndrome . Affected muscles: ECRB, supinator, ECU, EDC, EDQ, EIP, APL, EPL, EPB . Radial tunnel syndrome: tenderness over radial tunnel, pain at the origin of ECRB with resistance of long finger extension, and pain with resisted forearm supination. DDx with C7 radiculopathy: no involvement of the triceps or wrist flexor musculature. Anatomy of the radial nerve motor branches in the forearm PIN APL, EPB supinator EPL, EIP EDC Abrams et al., J Hand Surg Am, 1997 Peripheral ulnar neuropathy vs C8 or T1 radiculopathy . CuTS: weakness of the ulnar nerve innervated muscles distal to the elbow, with corresponding sensory changes . FCU, FDP (4,5), interossei, hypothenar muscles . Guyon’s canal syndrome . DDx muscles: FPL, thenar musculature, FDP (2,3) . True C8 or T1 radiculopathy: sensory disturbances on both the volar and dorsal surface, motor deficits of median nerve‐ innervated muslces, such as the T1‐dependent thenar muscles. Peripheral ulnar neuropathy vs C8 or T1 radiculopathy Cubital tunnel syndrome . Clawing of the small and ring fingers . Atrophy of the ulnar nerve‐innervated intrinsic muscles Cubital tunnel syndrome . Paresthesia and numbness in the little finger and ulnar side of the ring finger Cubital tunnel syndrome . Tinel’s sign Cubital tunnel syndrome . Wartenberg’s Sign . Ulnar nerve innervated palmar interossei: weak . Due to unopposed ulnar insertion of the extensor digiti quinti . Little finger abduction Cubital tunnel syndrome . Froment’s sign . Ulnar nerve innervates the adductor pollicis and interossei muscles, which provide adduction of the thumb and extension of the IP joint. FPL muscle tries to compensate for the loss of power to maintain pressure to the grip. Distal phalanx of the thumb markedly flexed. Cubital tunnel syndrome . Testing FDP 4,5 power Cubital tunnel syndrome Cubital tunnel syndrome Thoracic outlet syndrome . Neurogenic origin (>90%), arterial origin (<1%), venous origin (3‐5%) . 20‐40 years, F>M (3‐4 times) . Thoracic outlet (interscalene triangle, costoclavicular space, thoraco‐coracopectoral space or retropectoralis minor space) . Bony abnormality (cervical rib, enlarged C7 transverse process, abnormal first rib or clavicle (exostosis, tumor, callus or fracture), congenital abnormality of scalene muscles Thoracic outlet syndrome . Neurogenic TOS: difficult to diagnose d/t absence of the standard objective test . Symptoms: pain, paresthesia, numbness, and/or weakness . Paresthesia in upper limb (98%), neck pain (88%), trapezius pain (92%), shoulder and/or arm pain (88%), supraclavicular pain (76%), paresthesia in all five fingers (58%), 4‐5 fingers (26%), 1‐3 fingers (14%) . Hand weakness or difficulty with fine manipulation, cold intolerance . Cervical motion may increase symptoms, headache may develop. J Hand Surg Am, 2012 Radiographs of a 55‐year‐old woman with neurogenic thoracic outlet syndrome. A. Measurement of the number of VVLR. In this case, the VVLR was 8 h2/(h1 1.06). The measured values of h1 and h2 were 18.7 and 15.4 mm, respectively. The VVLR was 8.8. B. Measurement of the number of VCAR. In this case, the level was 8 h3/(h3 h4). The measured values of h3 and h4 were 9.0 and 10.4 mm, respectively. The VCAR was 8.5. Conclusion . Clinical manifestations >> EMG or imaging studies . Distribution of sensory deficit, motor evaluation, provocation test . Possibility of double crush syndrome, Concurrence of more than two diseases among the cervical radiculopathy, TOS and peripheral neuropathy Thank you for your attention.
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