DIFFERENTIAL DIAGNOSIS AT THE CERVICAL SPINE 1.

Arthritis Presents with a capsular pattern Degenerative osteoarthritis Inflammatory arthritis Traumatic 2. Matutinal headaches Ligamentous contracture around atlanto-occipital & atlanto-axial joints ‘old man’s matutinal headache headache’ (Cyriax 1982) 3.Tinnitus & vertigo ? ass symps of degenerative osteoarthrosis ? vertebrobasilar system 4.Osteophytic root palsy Elderly pt Gradual onset of arm aching with ? paraesthesia Obj neuro signs or arm weakenss affecting 1 n.root only Disc lesions presenting this way are unusual in this age group( Kesson&Atkins 2005) 5. Cervical Myelopathy Osteophytes, a disc prolapse or ligamentous fold causing central canal stenosis exerting pressure on spinal cord Pain,dysaesthesia of hands= numbness, P/N, clumsiness, & weakness Weakness & evidence of spasticity of lower limbs( Connell&Wiesel 1992) 6. Zygapophyseal joints Synovial joint prone to degeneration. Aprill et al 1989 suggest distinct referral patterns. Schwarzer et al 1994 refute existence of facet joint syndrome 7. Cervicogenic headache Cmn to upper 3 segments Aching, or deep pain localised to the neck, suboccipital & frontal region Agg/ neck mvts or sustained neck postures esp flexion ↓ PROM, mm contour changes, texture or tone, + abn tenderness( Beeton&Jull 1994) Other= nausea, visual disturbances, dizziness, or lightheadedness

Draft 1: Differential Diagnosis at the Cervical Spine Tendayi Mutsopotsi 2006

8. Polymyalgia rheumatic Middle- older age grp Women>men Symps= pain & stiffness to neck + shd girdle Low grade fatigue, low grade fever, depression & wght loss Rx= small dose of oral corticosteroids ( Hazelman 1995) 9. Temporal arteritis Closely related to above Cmn in elderly Vasculitis of unknown cause Symps= severe temporal headache & scalp tenderness.Causes blindness Rx= urgent high dose steroids 10. Rheumatoid arthritis Uncommon in Cx affects Women>men >40-60yrs Relapsing & remitting course Inflamn + thickening of synovium→cont with vascular tissue→pannus→destructn of ligaments,cartilage & bone ( Walker 1995) Maybe silent in Cx. Potential hazard to brainstem + cervical spinal cord Atlanto-axial sublux common manifestation Canial settling- vertical intrusion of the dens Subaxial subluxation ( Zeidman & Ducker) 11. Spinal Infections e.g osteomyelitis or epidural abcess staphylococcus aureas, mycobacterium tuberculosis, rarely brucella ( Kumar&Clark 2002) 12. Malignant disease > extradural Bone metastases frm primaries in bronchus, breast, prostate, kidney, or thyroid Symps= grad onset pain + stiffness Unrelenting + night pain not relieved by different postures o/e= AROM pain + ↓ ROM in all directions Isom pain + possibly weakness PROM prevented by mm spasm

Draft 1: Differential Diagnosis at the Cervical Spine Tendayi Mutsopotsi 2006

Neuro= mm weakness involving several n. roots (? Bilateral) unlike disc lesions ( Matthews 1995) 13. Primary tumours e.g meningioma, neurofibroma, glioma pain not usually a feature. Gradual onset of symps of cord compression 14. Pancoast tumour Carcinoma of apex of lung may erode the ribs and involve lower brachial plexus Symps= Pain++ shd & down medial aspect of arm with T1 palsy S/F away frm painful side maybe only ↓ ROM + passive elevation of shd on symptomatic side (Cyriax 1982) Horners syndrome- constriction of pupil & dropping of eyelid on the side of tuomour thru interruption of sympathetic ganglia ( Kumar&Calrk 2002) 15. Suprascapular, Long thoracic & spinal accessory neuritis Viral infection or trauma or unknown Symps= scapula & upper arm pain> 3wks duration O/E= painfree FROM Cx Weakness in appropriate mm Spontaneous recovery over 6 weeks Suprascapular neuritis= SST + IFST Long thoracic neuritis= SA Spinal accessory neuritis= STM & Traps 16. Neuralgic amyotrophy Unusual cause of pain++ in neck and scapular region with bizarre pattern of mm weakness in IFST, SST,Deltoid, Triceps, & SA Unknown cause ? viral infection, immunisation, allergic basis ( Kumar&Clark 2002) Recovers spontaneously over wks or months 17. Thoracic Outlet syndrome Compression, entrapment, or postural alterations affecting brachial plexus + accompanying vascular structures Distal symps C8,T1 Burning, dull aching pain to medial aspect of forearm Distal oedema with actvitiy, sweatiness, heaviness, circulatory changes Paraesthesia as release phenomenon @ night Debate continues abt its existence( Walsh 1994) 18. RSD now CRPS Complex limb disorder without obvious n. involvement

Draft 1: Differential Diagnosis at the Cervical Spine Tendayi Mutsopotsi 2006

Symps= persistent peripheral burning + tenderness= hyperaesthesia or allodynia Vasomotor + sensory changes- sweating, colour changes & trophic skin changes + weakness, tremor, mm spasm & contractures (Herrick 1995) 19. WRSUL Repetitive occupational overuse exceeding certain threshold of activity eg tenosynovitis or tendinopathy or a catalogue of non-specific symps perhaps leading to Anxiety & depression (Bird 1995) 20. Fibromyalgia > women Symps= Complex & variable including widespread m/s neck pain, shd, & upper limbs. Fatigue, headache, waking unrefreshed, subjective distal swelling, poor concentration, forgetfulness, & weepiness (Doherty 1995) Main diagnostic features= multiple hyperalgsic tender spots & non-restorative sleep Mx .eg relaxation techniques, exercise, pacing, hydrotherapy, physio, acupuncture, mm relaxants, & drugs to improve sleep quality 21. Drop attacks Episodic lower limb weakness causing falling without loss of conciousness Cause: brainstem related changes to lower limb tone & appear related to TIAs ( Kumar&Clark 2002) Instability of atlanto-axial joint, deformed odontoid process, Cx spondylosis or spondylolisthesis ( Cyriax 1982, Hinton et al 1993) Down Syndrome- associated with subluxation of atlanto-axial joint & hypermobility of the atlanto-occipital joint 22. Kleppel-Feil syndrome Ass with ↓ ROM, short neck, & low hairline. Dvptal abnormalities + congenital fusion of Cx vertebrae 23. VBI Dizziness & nausea main symps ass. With ↓ bld flow to brain Related to particular head position e.g looking up ( Toole & Tucker 1960) Cause: - extrinsic factors – degenerative changes with osteophyte formation to IV, Facet + joints of Luschka, anatomical anomalies in course of arteries - intrinsic factors- arterial disease & thrombosis Wallenberg’s syndrome or lateral medullary syndrome from brainstem infarction caused by VBI pathology (Kumar&Calrk2002) Cmn site of injury level of atlanto-axial joint

Draft 1: Differential Diagnosis at the Cervical Spine Tendayi Mutsopotsi 2006

24. Traumatic Injuries Fractures of C1 & C2 Neural arches Hyperextension cmn cause & probably stable. Rx polythene collar 3/12 Hangman’s # - pedicles of the axis - hyperxtension ass. With distraction & lethal -hyperextension & compression frequently without cord compression Rx collar 3/12 Jefferson # - fracture of ring of atlas Odontoid #s – high velocity accidents or severe falls involving rotation or shearing forces. Cord damage is uncommon Rx reduction by skull traction 3-6 wks then extensive plaster to 12wks Fractures C3-C7 Anterior wedge # Uncommon & stable. Collar for comfort Burst # Stable + painful, fragments close to spinal cord Rx plaster collar safest ^wks then polythene collas Dislocations Dislocation without fracture- posterior ligaments ruptured & spine is instable Rx skull traction, plaster collar, fusion Fracture dislocation- extremely unstable & often ass with cord damage Rx skull traction 3 weeks for reduction

Draft 1: Differential Diagnosis at the Cervical Spine Tendayi Mutsopotsi 2006

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