Orthopaedic Neurology: A Diagnostic Guide to liberary/Orthopaedic...  ORTHOPAEDIC NEUROLOGY A Diagnostic

  • View
    221

  • Download
    20

Embed Size (px)

Text of Orthopaedic Neurology: A Diagnostic Guide to liberary/Orthopaedic...  ORTHOPAEDIC NEUROLOGY A...

  • A Diagnostic Guide to Neurologic Levels

    ( \

    I

    ,

    www.

    ptho

    meg

    roup

    .com

  • ORTHOPAEDIC NEUROLOGY

    A Diagnostic Guide to Neurologic Levels

    Stanley Hoppenfeld, M.D. Associate Clinical Professor of Orthopaedic Surgery and Director of

    Scoliosis Service, Albert Einstein College of Medicine; Deputy Director of Orthopaedic Surgery and Attending Physician, Bronx

    Municipal Hospital Center; Associate Attending, Hospital for Joint Diseases New York, New York

    In collaboration with

    Richard Hutton

    Medical Iilustrations by

    Hugh Thomas

    A liPPINCOTT WILLIAMS & WILKINS A Wolters K1uwer Company

    Philadelphia Baltimore New York london BuenOS Aires Hong Kong Sydney Tokyo

    www.

    ptho

    meg

    roup

    .com

    http://booksmedicos.org
  • Contents

    Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Motor Power .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Sensation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Reflex................................................................... 2

    PART 1. NERVE ROOT LESIONS BY NEUROLOGIC LEVEL

    Chapter 1. Evaluation of Nerve Root Lesions Involving the Upper Extremity......... 7 Testing ofIndividual Nerve Roots CS to Tl ......................... 7

    Neurologic Level CS. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 7 Neurologic Level C6........................................... 13 Neurologic Level C7. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . 17 Neurologic Level C8........................................... 21 Neurologic Level TI........................................... 23

    Clinical Application ............................................... 28 Herniated Cervical Discs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 28 Cervical Neck Sprain versus Herniated Disc. . . . . . . . .. . . .. . . . . . .. 39 Uncinate Processes and Osteoarthritis. . . . . . . . . . . . . . . . . . . . . . . . . .. 40 General Tests for Reproducing and Relieving Symptoms of

    Osteoarthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 42 Nerve Root Avulsions ............... .......................... 42

    Chapter 2. Evaluation of Nerve Root Lesions Involving the Trunk and Lower Extremity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 45

    Testing ofIndividual Nerve Roots T2 to S4 ......................... 45 Neurologic Levels T2-Tl2 ..................................... 45 Neurologic Levels TI2-L3 ..................................... 47 Neurologic Levels 1.4 ......................................... 51 Neurologic Levels 1.5 ......................................... 57 Neurologic Levels S 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 61 Neurologic Levels S2, S3, S4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 64

    Clinical Application ................... ........................... 66 Herniated Lumbar Discs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 66 Low Back Derangement verSus Herniated Disc. . . . . . . . . . . . . . . . . .. 67 Spondylolysis and Spondylolisthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 68 Herpes Zoster. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Poliomyelitis. . . . . . . . . . . . . . . . . . .. ............................. 72

    PART II. SPINAL CORD LESIONS BY NEUROLOGIC LEVEL ................ 75

    Chapter 3. Cervical Cord Lesions: Tetraplegia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 77 Evaluation of Individual Cord Levels - C3 to T1 ..................... 77

    Neurologic Level C3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 77 Neurologic Level C4........................................... 79

    xi

    www.

    ptho

    meg

    roup

    .com

    http://booksmedicos.org
  • xii Contents

    Chapter 3. Cervical Cord Lesions: Tetraplegia-(Continued) Neurologic Level C5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 80 Neurologic Level C6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 81 Neurologic Level C7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 82 Neurologic Level C8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Neurologic Level TL. . . . . . . . . .. .. .. .. . . . ... .. .. . . . . . . . . . .. .. .. 83

    Upper Motor Neuron Reflex ....................................... 84 Clinical Application ............................................... 85

    Fractures and Dislocations of the Cervical Spine. . . . . . . . . . . . . . . . . 85 Herniated Cervical Discs....................................... 91 TUmors of the Cervical Spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Tuberculosis of the Spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 91 Transverse Myelitis . . . . . . . . . . .. . . . . . . . . . . . .. ......... 91

    Chapter 4. Spinal Cord Lesions Below Tl, Including tbe Cauda Equina . . . . . . . . . . . .. 93 Paraplegia ....................................................... 93

    Neurologic Level Tl-TI2....................................... 93 Neurologic Level Ll. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 94 Neurologic Level L2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 94 Neurologic Level L3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 94 Neurologic Level L4 ......................................... " 94 Neurologic Level L5. .. .. .. .. . . . . . . . . . . . . .. . . . . . . . . . . . . .. .. . . .. 95 Neurologic Level SI ................... , .. , ........... ' .. " . . .. 95

    Upper Motor Neuron Reflexes ................ .................... 95 Clinical Application ............................................... 96

    Further Evaluation of Spinal Cord Injuries. . . . . . . . . . . . . . . . . . . . . . . 96 Herniated Thoracic Discs ....................................... 100

    Evaluation of Spinal Stability to Prevent Further Neurologic Level Involvement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .......... 10 I

    Chapter 5. Meningomyelocele ................................................. 107 Determination of Level and Clinical Application ..................... 107

    Neurologic Level Ll/L2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 109 Neurologic Level L2/L3 ....................................... 109 Neurologic Level U/L4 ....................................... II I Neurologic Level L4/L5 .............. . . . . . . . . . . . . . . . . . . . . . . . .. I 13 Neurologic Level L5/S1 ....................................... 116 Neurologic Level S I/S2 ....................................... 118 Neurologic Level S2/S3 ....................................... 118

    Milestones of Development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Unilateral Lesions ............................................... " 119 Hydrocephalus ................................................... 119 Involvement of the Upper Extremity ....................... 119 Suggestions for Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

    References ........................................................ 121 Index ....................................................................... 127

    www.

    ptho

    meg

    roup

    .com

    http://booksmedicos.org
  • Introduction

    The spinal cord is divided into segments. Nerve roots exit the spinal cord at each seg-mental level, and are numbered in relation to the level from which they exit. There are eight cervical, twelve thoracic, five lumbar, and five sacral nerves. The C5-T I segments innervate the upper extremity, and the T 12-S4 segments the lower extremity; these two sections of the cord have the greatest clinical significance.

    Pathology affecting the spinal cord and nerve roots commonly produces symptoms and signs in the extremities according to the specific neurologic levels involved. These levels can usually be diagnosed clinically,

    . since each level of injury has its own charac-teristic pattern of denervation.

    The common denominator in injuries to ei-ther the cord or the nerve root lies in the seg-mental pattern of alteration of motor power, sensation, and reflex in the extremities. Evalu-ation of the integrity of the neurologic levels depends upon a knowledge of the derma-tomes, myotomes, and reflexes. Different der-matomes (areas of sensation on the skin sup-plied by a single spinal segment) and myo-tomes (groups of muscles innervated by a single spinal segment) are affected depending upon the level involVed and upon whether the pathology involves the cord or the nerve roots emanating from it. It is through a clinical eval-uation of motor power, sensation, and reflex that the correct neurologic level of involve-ment can be established.

    MOTOR POWER

    The impulses that supply motor power are transported in the spinal cord via the l?ng tracts, and in particular via the cor