Dx of the skull: Paget’s of the skull (increased hat size ...



Dx of the skull: Paget’s of the skull (increased hat size and alk phos [all bone tumors too]). Two reasons to X-ray skull and the third is who cares. Concern is not for the bones, but for the brain. These are generally best referred out. DON’T EVER TAKE A SKULL FILM.

Dx of C/S: 15% of population have arcuate foramen (tends to run in family, calcification of AO ligament. Twisting injury of spine might cause damage to artery. One study states this is a contra-indication to manipulation, but this is arguable. May present with HA). Most common area of congenital fusion in C/S is C2/C3 – looks like very long odontoid. Another very common finding is spina bifida of C1, perhaps as high as 15% of population, often associates with large anterior tubercle. Also a dysplastic posterior arch. In children, as the bone is developing, the GU system is developing at the same time (consider an IVP if you find bony anomalies). Fused segment is an indication for stress X-ray because of instability.

Standard dose for cancer Tx is 6500-7200 rads spread out daily over 5 weeks. Standard exposure in 5 view cervical is 1/7 rad per shot.

C2 hangman’s fracture most common fracture of C/S.

C5 disc should be the largest in the C/S

Eagle’s syndrome – calcification of the styloid ligament.

Clay shoveler’s fracture – no treatment. It will never re-attach.

Teardrop fracture two type: flexion and extension. Flexion drives the avulsion posterior into the cord, extension drives the avulsion away from the cord.

WHIPLASH: The epidemic

H.E. Crowe, MD, in 1928, was the first to use the term whiplash. Many terms coined, but this one stuck. Various studies show:

• Of 266 medlegal cases of whiplash, 45% were still symptomatic two years after settlement.

• 36 of 173 remained symptomatic after one year.

• 44-90% remained symptomatic after 22 months.

• After 10 years, only 12% fully recovered.

More than 50% of cervical acceleration/deceleration (CAD) injuries have an associated low back injury (Croft and Foreman).

• Muscle/ligament tear

• Fracture

• Thyroid injury

• Retro-ocular hemorrhage

• Retropharyngeal hemorrhage

• Core contusion

• Subarachnoid hematoma

• Disc rupture

• Microfracture

• Brain injury

• Retrotracheal hemorrhage

• Nerve root contusion

These lesions have been seen in humans as well:

• Military and civilian experiments

• Autopsy reports

Biomechanics of whiplash

5

4

3

2

1

0

-1

-2

-3

-4

50 100 150 200 250 300

The victim’s head and neck are subjected to 2 ½ times that of the vehicle.

Law of conservation of linear momentum:

e = (U1-U2)/(V1-V2)

e = 0 plastic collision

e = 1 elastic collision

The new VW bug is elastic and imparts more injury on the occupant rather than absorbing the energy.

Conditions affecting the outcome and severity of the injury:

• Mass of vehicles: a streetcar traveling at a speed of 3 mph will produce the same damage as a compact car traveling at 40 mph

• Ramping: what was the position of your seatback.

• Proximity of head restraints

• Seatbelt and shoulder harness: consider the third most common type of pain is shoulder pain

• Other important conditions:

- Brakes

- Road conditions

- Seatback stiffness

- Compressibility of cars

- Second collision

Human factors that affect the outcome and severity of the injury

• Age

- Tissues are less elastic

- 40% less in ROM (lipstick sign)

- Need longer healing time

- 25% loss of strength

- Slower reaction time

• Sex - Shutt and Dohan found a higher incidence of neck pain in women (at 6 months, 75% still symptomatic). Neck size related to musculature is significant.

• Other important human factors:

- Position of head at impact

- Surprise collision

- Pre-existing conditions (degenerative disc disease)

Documenting the soft tissue injury:

1) Careful history and exam

2) Accurate, complete history notes

3) X-ray

4) CT scan to document disc herniation or fracture

5) MRI for documenting is the best to show soft tissue and bone bruise injury (cord tumor, trauma, idiopathic - most common causes of syrinx)

6) Fluorovideo motion analysis (FMA) to document ligamentous instability (one of the most important tools in CADS cases).

7) Thermography. Based on skin temperature. Dependent upon vasomotor sympathetic control. It is easy to manipulate readings – simply run your finger up the sciatic nerve length and immediately take a picture and you have a hot sciatic nerve syndrome. Done properly and legitimately, this is an extremely valuable diagnostic procedure.

8) Other tests include radionuclide bone scans, CYBEX testing and electrodiagnostic studies (EMG, NCV, DSSEPs)

9) Medical photography (will save information for court)

Prognosis: why does the pain last o long?

1) Muscle heals with collagen scar: this scar is weaker and less elastic than normal tissue and is supersensitive. Immobility and rest will alter proper nutritional regimens and increase scar tissue formation.

2) Ligaments heal poorly and incompletely due to poor blood supply; this results in chronic instability. Ligament injury leads to hypermobility/instability and the body will stabilize this (OA).

Injury(ligamentous instability pain muscle spasm altered biomechanics

Sclerotogenous pain

• Kellgren, 1939

• Inman and sanders, 1944

• Feinstein et al., 1954

• This pain varies from the classic picture of pain

• Helps to explain “mysterious symptoms”

What about the future?

• Chronic instability

• Degenerative disc disease

• Spondylosis

HOHL found an incidence of degenerative change in 39% of patients sustaining CAD injury compared to a 6% incidence in age matched controls. CROFT and YOUNG have noted a very high correlation between …

Probably more than 7% of all Americans suffer from CADs residuals

Head injuries:

• The post-concussion syndrome

• Post concussion headache

• Includes: HA, neck pain, dizziness, difficulty concentrating, intolerance to alcohol, personality changes, insomnia, irritability, anxiety, memory loss

• These conditions have historically been passed off as litigation neurosis. Rent studies have shown that these entities are in fact real.

• Wickerstrom, Ommaya, and Liu have produced EEG evidence of concussion in primates following whiplash (without loss of consciousness). Autopsies of humans…

• Diffuse axonal injury (DAI)

- Retraction balls

- Microhemorrhages

- From shear forces

- Probable cause of PCS

Biomechanics of the soft head injury

When a car is struck from the rear and accelerated to 10.8 mph within 100 msec, the occupants have a 50:50 chance of sustaining a cerebral concussion.

Documenting the soft head injury:

1) EEG – poor method

2) ENG – if vestibular symptoms are present

3) BAER – if brainstem is involved

4) VER – not usually helpful

5) BAEM (brain area energy mapping)

Prognosis of posttraumatic HA

• 40-60% lasted more than 2 months

• 60% lasted more than 6 months

• 33% lasted more than 1 year; 15-20% lasted more than 3 years

• 31% lasted more than 5 years

TMJ trauma

Trauma occurs at the time of injury and in the aftermath, due to complex biomechanical interactions between the neck and the TMJ.

TMJ injuries require coordinated care between …

Were does the DC fit in?

• Manipulation is the only effective way to reduce fixations/subluxations

• PATIENT modalities to prevent excessive scar and manage pain

• DCs have the most experience with these soft tissue lesions

Whiplash injuries

CNS – vascular and direct nerve injury

Vascular – especially vertebral artery (AO ligament, post arch C1, lateral mass C1 to C2

Bony – micro fractures

Muscular – longus colli (extension), suboccipital (flexion)

Ligaments – 20% delayed instability in hyperflexion when post elements torn

Other:

Esophagus perforation

Breast – cancer?

Nerve roots – double crush syndrome

Discs – ant long big and post annulus

Sympathetic chain – Horner’s syndrome

TMJ – anterior subluxation, muscle strain

Low back – side wall and seat belt

Whiplash symptoms

1. Neck pain 78-100%. Delayed 24-48 hours. Females > males

2. HA 48-92% “Post traumatic headache syndrome”, headache, neck pain, dizziness, memory loss, immu, irritability, depression, anxiety, intal alcohol, personality changes, difficult females > males (3 types: common, migraine, ) 31%

3. Pain or paresthesia in upper extremity 7-75%

4. Dyphagia – muscle spasm vs esophagus tear 10-30%

5. Weakness – fatigue (psychosomatic?)

6. Visual symptoms/auditory – blurred nystagmus, tinnitus (TMJ)

7. Shoulder pain – muscle strain, disc referred, sclerotomal

8. Dizziness – sympathetic, vascular, visual

Prognosis scale

MIC 1 –(major injury category), symptoms directly relating to injury but no objective findings on PE.

MIC 2 – MIC 1 + decreased ROM of C/S + increase of cervical diameter. No neurological signs

MIC 3 – MIC 1 plus MIC 2 plus objective neurological loss (either sensory or motor)

Point scale adds as follows:

MIC 1 starts with a point vale of 10

MIC 2 starts with a point vale of 50

MIC 3 starts with a point vale of 90

Add to the above the following findings:

|Modifiers |Point value |

|Canal size 10-12 mm |20 |

|Canal size 13-15 |10 |

|Straight cervical curve |10 |

|Kyphotic curve |15 |

|Loss of consciousness |15 |

|Fixed segment (flexion/extension) |15 |

|Preexisting degeneration |10 |

1 - (10-30 points) excellent. Occasional, mild muscle pain and/or occipital HA

2. (35-70), generally good, residual, acc to intermittent, moderate neck pain

3. (70-105)

4. (105-125), guarded, future or persistent neuro defects, sign of decreased grip strength, atrophy radiculitis myelopathy, fair probability surgery

5. (130-165), unstable, not likely to improve much, surgical intervention probable, radiculopathy and myelopathy

High speed is not necessary to induce injury, low speed can cause injury too. Injury occurs in the first 50-75 milliseconds of accident where the upper C/S is in flexion while the lower C/S is in extension.

Treatment

RICE – 1-5 days

Soft collar – traction should relieve symptoms, if not, no collar. No atrophy

Gentle massage – muscle spasm/drainage

Ultrasound – aid phagocytosis

High volt galvanic, TENS, electro-acupuncture

Early mobilization

Isometric exercises

After acute injury stage

Cervical traction ( fibrous adhesions, ( healing muscles, preheat (moist), head traction first, good leg – polyaxial cervical traction

Medications – watch for dependency. Tryptophan and vitamin B6 (pain), vitamin C and zinc (healing)

manipulation

Worst case C/S is RA

Most common arthritide in C/S is DDD

All arthritides will have decreased disc space

OA: subchondral sclerosis, osteophytes, subchondral cysts (geodes). Uncinate hypertrophy will affect the IVF (this will not happen with DISH). Stiffness, pain, and decreased ROM. Very common and responds really well to adjustments. Facets disappear because of hypertrophy.

RA: subchondral lucency, typically doesn’t effect the discs. ADI is concern do stress shots. Small joint most commonly affected. 95% of people with RA in the hands will have it in the neck. 30% will have X-ray findings of ADI instability. Reduces life span by about 20 years. Typically die from basilar invagination. Facets disappear because of synovial erosion.

Often-times, OA will follow RA, especially when RA inflammation is in remission.

DISH: flowing exuberant bone with preservation of discs. Difficulty swallowing, restricted ROM. Can affect eyes and heart.

Vacuum cleft - gas caught in the disc space only on stress views.

Intercallary bone – ossification within the disc

Most common C/S fracture is the C5 lamina.

All C/S surgery carries a 2% risk of infection - lifelong.

You probably will not see infection or tumor in the C/S in your entire career. Most likely tumor to see in the C/S is mets.

Flexion/extension studies in anyone with suspected instability.

Hopenfeld table 1: neurology of the upper extremity

SHOULDER

Common Board brachial plexus type questions:

Erb’s palsy – seen in childbirth with injury to the C5 nerve root (+/- 1). Leads to the “waiter’s tip” deformity. 90-95% heal over time. May see this in whiplash injuries or OA. This is like an axonotemesis injury.

Klumpke’s – the dreaded claw hand deformity. Injury in the C6/7/8/T1 region. T1 is the beginning of the sympathetic chain meaning possibility of Horner’s syndrome presentation. Common in motorcycle accidents.

Rotator cuff injury is common, all chiropractic persons tend to get this. 99% of shoulder injury is soft tissue related. This sort of injury will not show up on X-ray and may not show up on MRI.

Three most common shoulder injuries: separation, separation, separation.

Most common shoulder fracture is the clavicle, classically in the lateral third of the bone. Humeral head fractures only in extreme traumas and, perhaps, in geriatrics.

In dislocation/separation, ask which joint, GH or AC. In GH, anterior or posterior. Classically, most common is the anterior subcoricoid GH dislocation (96%). Presentation is with patient antalgic away from anterior dislocation side unable to hold arm with good hand. Posterior dislocation or AC joint separation, patient can hold dislocated arm with good arm. Legally, chiropractic can not reset GH dislocation – 1/3 of them have associated fractures. Common fractures include the inferior labrum (Bankart) and the greater tubercle of the humerus.

Hill-Sach’s lesion – divot on the inferior head of the humerus showing in chronic dislocators. As a person starts dislocating, they stand a higher and higher chance of re-dislocating.

AC joint. Usually resulting from direct blow to the shoulder in sports resulting in separation causing a tear in the ligamentous support structures.

Grade 1 – pain/swelling perhaps some tearing

Grade 2 – acromion is slightly depressed to clavicle with some tearing of inferior supporting ligaments.

Grade 3 – acromion detached from clavicle with tearing of inferior support ligaments. Lots of pain. Requires surgery.

Tumors

Children – osteosarcoma most common in the knee, but can occur at the ends of long bones. Also Ewings.

Benign tumors – osteochondroma.

Arthritis – RA in the shoulder is usually unilateral and will eat the long head of the biceps. OA of the shoulder is not uncommon

Notch on the clavicle is the rhomboid fossa is a normal variant.

Clavicle is the first bone to start ossifying and the last one to complete ossifying.

Soft tissues around the clavicle, clavicular shadow, looks like elevation of periosteum is normal.

Dysplastic glenoid, like a dysplastic acetabulum.

Klippelfeil plus elevated scapula and omohyoid is Sprengel’s deformity. Consider MR to note for underlying neural problem (syrinx).

No clavicles – cleidocranial dysostosis

Scapula fracture – something you will never see, the rarest fracture to occur

If you see a superior dislocation of the humerus, the national board answer is RA (biceps tendon eaten away allowing shoulder to rise).

Second most common complaint is shoulder complaint (after LBP). Very common in swimmers, OA of the AC joint with an acromial osteophyte growing into the supraspinatus tendon.

Pain from the acromion medial is usually neck, acromion distal is shoulder.

If the humeral head elevates because of RA, to test, as the person abducts the arm, push down on the head of the humerus to reset it into the glenoid and the patient will be able to complete abduction without pain.

50% of syrinx are caused by cord tumors. Second most common cause is trauma (especially of the shoulder). Third cause is idiopathic (?).

osteochondroma

Avascular necrosis of the humerus (like the femur) is not uncommon. Most common in age 20-40 male. Four high risk types associated with this: sickle cell, steroid use, alcoholism, gout – anything that can clog up the veins of the ends of the bones. You will see this in your office.

Paget’s: after X-ray, get bone scan, base line chem screen, and send them for pharms to halt progress.

TOS: classic distribution is ulnar distribution (same distribution as heart attack). Pain, numbness, and/or paresthesia aggravated when raising the arm over the head. TOS tests: anterior scalenous (Adson’s – taking pulse helps differentiate between vascular and neurologic. This is not a very common syndrome.), costo-clavicular (costo-clavicular/Eden’s/military test – this is most likely cause of TOS. Broken clavicle and job related are predisposers. Also consider Pancoast tumor.), corcoid (Wright’s test. The pulse on most people will diminish. Again, you are looking for to reproduce c/c). finally, there is a general TOS in which you do Roo’s test for 3 minutes. Other tests to consider: Speed’s, head shoulder depression (don’t push on the head). Another concern on the national boards is cervical rib (remedy is surgical removal with 90% success rate).

Age will exacerbate the predisposed persons, as will job duties or weight lifting.

Neurological TOS is 95+%, vascular TOS is ................
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