PANCE Blueprint Musculoskeletal (8%)

Cervical herniated disk

• Young middle age mid 30's
• Cervical disk: Pain into the arm/shoulder pain, numbness and tingling pain into the arm with pain at rest – versus rotator cuff no pain at rest unless there is movement
• MRI is confirmatory – soft collar, NSAIDS, muscle relaxants, epidural steroid injections, surgical consultation if not responsive to conservative treatments

Cervical radiculopathy

• C4
  • May affect the levator scapular and trapezius muscles, resulting in weakness in shoulder elevation. There is no reliable associated reflex.
• C5
  • Weakness of the rhomboid, deltoid, bicep, and infraspinatus muscles. Patients may have weakness of shoulder abduction and external rotation. The bicep reflex may be diminished.
• C5-C6
  • Affects the C6 nerve root and produces pain at the shoulder tip and trapezius with radiation to the anterior upper arm, radial forearm, and thumb, and sensory impairment in these areas. C6 radiculopathy can easily be confused for C5 or C7 radiculopathy. Weakness can overlap with the C5 or C7 muscles. Muscles affected include infraspinatus, bicep, brachioradialis, pronator teres, and triceps. Weakness involves flexion at the elbow, or shoulder external rotation. The bicep or brachioradialis reflex may be diminished.
• C6-C7
  • Affects the C7 nerve root and produces pain at the shoulder blade, pectoral area, and medial axilla with radiation to posterolateral upper arm, dorsal elbow and forearm, index and medial digits or all of the fingers, and sensory impairment in these areas. C7 radiculopathy can result in weakness of the triceps, pronator teres, flexor carpi radialis. Weakness involves the elbow extensors and forearm pronators. There may be a diminished triceps reflex.
• C7-T1
  • Causes C8 radiculopathy. Weakness can be present in the opponens pollicis, flexor digitorum profundus, flexor pollicis longus, and hand intrinsic muscles. Clinically, patients present with symptoms similar to an ulnar or median motor neuropathy and can have weakness of finger abductors and grip strength; they may also have findings suggesting median motor neuropathy. No reliable reflex test is available.

Lumbar herniated disk

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Pain in a dermatomal pattern - increases with coughing, straining, bending, and sitting

• L5-S1 is most common
• Also L4-L5

Clinical Manifestations

• Sciatica: back pain radiating through the thigh and buttocks - lower leg (below knee) down L5-S1 dermatome
• Physical Exam: + straight leg raise, + crossover test

Diagnosis

• Noncontrast MRI is confirmatory

Treatment

• NSAIDS, rest, steroids and physical therapy
• Epidural steroid injections
• Surgery if warranted

Look for "red-flag" symptoms:

Lumbar radiculopathy most commonly involves either the L5 or S1 root.

• L1
  • Rare - symptoms involve pain, paresthesia, and sensory loss in the inguinal region.
• L2, L3, and L4
  • In older patients with spinal stenosis. They are generally considered as a group because of marked overlap of innervation of the anterior thigh muscles. Acute back pain is the most common presenting complaint, often radiating around the anterior aspect of the thigh down into the knee.
• L5
  • The most common radiculopathy affecting the lumbosacral spine. It often presents with back pain that radiates down the lateral aspect of the leg into the foot. On examination, strength can be reduced in foot dorsiflexion, toe extension, foot inversion, and foot eversion. Reflexes are generally normal.
• S1
  • Pain radiates down the posterior aspect of the leg into the foot from the back. On examination, strength may be reduced in leg extension (gluteus maximus) and plantar flexion. Sensation is generally reduced on the posterior aspect of the leg and the lateral foot. Ankle reflex loss is typical.
• S2, S3, and/or S4
  • Patients can present with sacral or buttock pain that radiates down the posterior aspect of the leg or into the perineum. Weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction. 

• Anterior thigh pain
• Sensory loss medial ankle

• Lateral thigh/leg and groin paresthesia and pain
• Dorsum of the foot especially between 1st and 2nd toes

• Posterior leg/calf
• Plantar surface of the foot

• Angle dorsiflexion

• Big to extension
• Walking on heels more difficult than on toes

• Plantar Flexion
• Walking on toes more difficult than on heels

• Loss of knee jerk
• Weak knee extension - quads

• Usually no diminished reflexes.

• Loss of ankle jerk