1. CLINICAL DIAGNOSIS OF CERVICAL DISORDERS Andradi S. Department of Neurology, University of Indonesia, Jakarta

3. CERVICAL DISORDERS Structures commonly involved: 1. Muscle, tendon 2. Skelet: vertebra, disk, facet joint, ligament 3. Nerve: spinal cord, radix, brachial plexus

4. PAIN SENSITIVITY 1. Periosteum 2. Ligament 3. Joint capsule 4. Tendon 5. Fascia 6. Muscle

5. CERVICAL DISORDERS RECOGNITION Dysfunctions of 1. MUSCLE 2. SKELET 3. NERVE MUSCLE NERVESKELET

6. MUSCLE DYSFUNCTION

7. MYOTOME and DERMATOME MYOTOME :Segmental innervation of muscle DERMATOME: segmental innervation of skin

10. MUSCLE DYSFUNCTION ●Manifestations: weakness, pain. ▪ Weakness: LMN type. ▪ Pain Characteristics: - pain, ache, stiff - felt at rest, lengthened, contract. - Distribution: localized, diffuse, referred. ● May be part of ▪ Myofascial pain syndrome Localized or referred pain with “trigger point” ▪ Fibromyalgia syndrome Diffuse with 18 “tender points”

11. MUSCLE PAIN Distribution: ● Local Pain ● Diffuse Pain ● Referred Pain Referred Pain: Muscle pain projected to corresponding dermatome

14. MYOFASCIAL PAIN SYNDROME “TRIGGER POINT” Point at which muscle pain is projected to trigger zone

16. FIBROMYALGIA SYNDROME 18 “TENDER POINTS”

18. DERMATOME Segmental innervation of skin

20. JOINT PAIN Pain characteristics : ▪ Sensation: pain, ache, stiff. ▪ Localized, diffuse, referred to segmental distribution (dermatome,or sclerotome). ▪ Comes or increases at any point of joint range of movement.

21. SCLEROTOME Segmental innervation of bone

24. NERVE DYSFUNCTION

27. Cardinal manifestations of nerve dysfunction: Motoric, sensoric, and autonomous symptoms. 1. Spinal cord ▪ Manifestations: motoric, sensoric, autonomous. ▪ Motoric : Weakness.LMN at level of lesion,UMN below lesion. ▪ Sensoric : segmental deficit below lesion. ▪ Autonomous: bladder and bowel incontinence.

28. NERVE DYSFUNCTION 2. Nerve root / radix a. Nociceptive pain (epineurum) ▪ Mechanical: aggrevated or eased on particular movement (“on/off pain”). b. Neuropathic pain (axon) ▪ Radicular pain ( radiating, electric-like,stabbing): neck to shoulder, arm and hand. ▪ Spontaneous: shooting, burning, lancinating. ▪ Dermatomal sensory deficit: paresthesia, hypesthesia. c. Upper limb paresis, LMN type.

29. COMMON CAUSES OF CERVICAL DISORDERS MUSCLE Muscle strain Fibromyalgia Myofascial pain Tendinitis SKELET Osteoartrosis NERVE Cervical spondylosis Cord compression Rheumatoid arthritis Radix compression Disk degeneration Myelopathy Fracture Tumor Plexitis/Neuritis Herpetic neuralgia Carpal tunnel synrome

30. DIAGNOSTIC WORK UP 1. HISTORY 2. PHYSICAL EXMINATION ■ General ■ Neurological 3. INVESTIGATIVE ■ Neurophysiology ■ Neuroimaging ■ Laboratory

31. HISTORY ■ COMPLAINT ● Systems: Motoric, sensoric,autonomous ● Temporal: duration, onset, course ● Causative factors: trauma, infection etc. ■ DISRIBUTION localized, diffuse, referred, radicular. ■ AGGREVATING and EASING FACTORS ■ PAST HISTORY

32. PHYSICAL EXAMINATION ■ GENERAL Posture of head, neck, shoulder, arm. Range of movement Deformity

33. PHYSICAL EXAMINATION ■ NEUROLOGIC EXAMINATION Motoric: power, trophy, tonus, fasciculation, reflexes. Sensoric: induced pain, deficit, “trigger point” (myofascial pain) “tender point” (fibromyalgia). Autonomous: sweat, oedema, trophic changes. Specific tests for pain: - Cervical Distraction Test : osteophyte, fascet joint. - Compression test (Lhermitte’s test): HNP, osteophyte. - Valsalva test: intracanal spinal tumor, HNP.

34. INVESTIGATIVE EXAMINATION 1. Clinical Neurophysiology EMG, SSEP 2. Neuroimaging Cervical X-ray, CTScan, CTMyelography, MRI, MR Myelography. 3. Laboratory CBC, CRP, tumor marker, etc.

36. CONCLUSION ☻ History and physical examination are the keys in the diagnosis of cervical disorders. ☻Recognition of the structure(s) involved, based on its characteristic clinical features, is the first step directing further procedure in the diagnosis. TREAT THE PATIENT NOT THE PHOTO !!!