Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4540_Библиотеки_им_академика_М_И_Перельмана.pdf
98
CHAP TER3 Thehead
bHemicrania continua
This is a persistent unilater al headache that is usually unremitting. The
pain is usually moderately severe, unilateral, and continuous, without
pain- free periods. There may also be lacr imation, nasal congestion, or
ptosis. The cause of hemicrania continua is unknown and there is no
denitive diagnostic test for it. However, it generally responds only to
indomethacin, which must be continued longterm.
Chapter4
99
The back oftheneck
Common presentations 100
Common problems and their causes 100
Useful questions and what to look for 101
Examination of the cervical spine following trauma 103
Useful investigations 108
Cervical spine plain lm interpretation in trauma 108
Specic injuries to the neck 112
Spinal cord injury/ lesions 115
Acute spinal cord compression 118
Dierential diagnosis of neck pain 119
Vertebrobasilar insuciency (beauty parlour syndrome) 120
Lump(s) in the back of the neck 121
100
CHAP TER4 The back oftheneck
Common presentations
• Injuries
• Lumps
• Pain/ stiness
• Vertebrobasilar insuciency (dizziness/ blackouts)
• Neurological symptoms.
Common problems and theircauses
Injuries
Common
• Neck sprain (‘whiplash’).
Uncommon
• Fractures of cervicalspine
• Dislocations of cervicalspine
• Hanging.
Pain/ stiness
Common
• Non- specic neckpain
• Neck sprain (‘whiplash’)
• Torticollis
• Degeneration/ cervical spondylosis
• Cervical radiculopathy.
Uncommon
• Rheumatoid arthritis
• Bone disorders
• Infections
• Tumours
• Carotid artery dissection
• Retropharyngeal abscess.
Miscellaneous conditions
Common
• Lumps (lymphadenopathy, lipoma, sebaceouscyst)
• Vertebrobasilar insuciency.
Uncommon
• Cervical cord myelopathy/ myelitis (non- traumatic).
USEF UL QU ESTI ONS AND WHAT TO LOOKFOR
Useful questions and what
tolookfor
Injuries
Askabout
• When it occurred
• Mechanism of injury (what happened)
• Where they aresore
• Any loss of consciousness or signs of headinjury
• Any peripheral neurological symptoms
• Progression of symptoms since time ofinjury
• Any other injuries (remember the entire spine).
Lookfor
• Other injuries following ATLS® principles
• Peripheral neurological decit
• Bony tenderness (as necessary)
• Priapism (as necessary).
Pain/ stiness
Askabout
• Onset, duration, and progression
• Character/ distribution (localized vs generalized)
• Possible causes (injury, posture, sleeping, sports)
• Peripheral neurological symptoms
• Symptoms in other joints.
Lookfor
• Range ofmotion
• Tenderness (midline vs muscles)
• Peripheral neurological decit.
• Otherjoints
• Neck masses/ swellings.
101
Lumps
Askabout
• Onset, duration, and progression
• Painful/ painless
• Any otherlumps
• Previous excision of skin or scalp lesions/ malignancies
• Exposure to pets and other animals/ recent travelabroad
• Systemic features (infection/ lymphoma/ malignancy).
102
CHAP TER4 The back oftheneck
Lookfor
• Assess character of lump (size, mobility, tenderness,etc.)
• Overlying skin (erythematous, blanching, stula, induration,etc.)
• Head and neck exam for primar y malignancies (nodes andscalp)
• Palpate other lymphatic sites (inguinal, axillary, supraclavicular)
• Examine liver and spleen.
Dizziness/ blackouts (suspected vertebrobasilar
insuciency)
Askabout
• Any precipitating events (head turning, chest pain,etc.)
• Other neurological symptoms (especially cerebellar or visual)
• Headaches
• Neck pain/ stiness
• Any injuries following blackouts
• Past medical/ drug history.
Lookfor
• Peripheral neurological decit
• Symptoms reproduced by careful neck movements
• Consider ECG monitoring
• Other possible causes (cardiac, CN S, diabetes,etc.)
Neurological symptoms
Askabout
• Onset
• Precedinginjury
• What the patient was doing when the symptomsbegan
• Determine whether pain/ paraesthesia/ paralysis
• Aggravating and relieving factors
• Any other neurological symptoms
• Weightloss
• Fevers
• PMH.
Lookfor
• Range ofmotion
• Tenderness (midline vs muscles)
• Peripheral neurological decit
• Symptoms reproduced by careful neck movements.
EXAMIN ATION OF THE CERVIC AL SPINE
Examination ofthe cervical spine
followingtrauma
Examination depends on the presenting symptoms and what associated
pathology/ injuries are suspected. Patients may walk into the accident
and emergency department with a relatively minor complaint, or they
may arrive on a spine board, with total spinal immobilization.
Low- risk factors forcervical spineinjury
• Simple rear- end MVC where the car wasn’t forced into the car
in front, hit at a high speed, or by a large vehicle.
• Ambulatory at any point after the injury.
• Sitting in the emergency department.
• Absence of midline spinal tenderness.
• Delayed onset of neckpain.
Examination ofthe non- injured neck, or theneck
following minor injuries
Although the ATLS® protocol dictates complete immobilization of the
spine, this is clearly not necessary (or practical) in every patient who
complains of neck pain. The trick is to know which patients do and which
ones do not need this. Knowing the mechanism of injur y or any preceding symptoms, while maintaining a high index of suspicion, will allow most
cases to be managed appropriately. If in doubt, err on the side of caution
and seek advice. Useful clues include:
• Age:young patients are more commonly associated with trauma
and congenital malformation, older ages with degenerative causes
(be cautious with older patients as minor trauma can result in
signicant injuries).
• Position:are they standing, sitting, or lying down. Have they been
fully mobile since the problem commenced?
• Posture:do they turn their head to see you or does their whole body
turn? Have they developed neck stiness and if so how severeisit?
• Clothing:Velcro®- style fastening vs tiny intricate buttons (may
indicate pre- existing neurological problems).
• Does the patient use any walking aids, standing frame, sof t collar etc.?
These also give clues about pre- existing patholog y.
• The hands:are these the hands of a rheumatoid patient?
Examination of the non- injured neck (or a neck following minor injuries)
can be considered under three elements:look, feel,move.
Look
• Can they look up or is there a cervical spondylosis?
• Can you see an incision from a surgical approach to the
cervicalspine?
• How exed is the cervicalspine?
• Note any thoracic kyphosis, muscle bulk , and skin changes.
• Are they inpain?
103
104
CHAP TER4 The back oftheneck
Feel
Most palpation in the cervical examination can be performed from
behind. It is often less tiring for the patient, and easier for you, if they
are sitting down. Star t at the occiput, working your way down over the
erector spinae and spinous processes. The highest bone you will feel will
be C2. Work down to T1, the most prominent bone in the neck . C7 may
also be prominent. To work out if you are on T1 or C7, ask the patient
to extend the neck slightly: C7 glides back, T1 does not. Palpate laterally, around and over trapezius into the supraclavicular fossae. Palpate
along the sternomastoid muscle, feeling for swellings, spasm, and tenderness. If symptoms suggest, continue advancing until your ngers meet
in the midline anterior ly and then examine the front of the neck (see
E Chapter 5).
Move (only possible ifa spinal injury is not suspected)
Always start with active (patient- initiated) movement to avoid hurting
the patient. If necessary, ask the patient to put a tongue depressor in
their mouth to act as a guide to the r ange. Ask the patient to hold their
head in a comfor table position. Note if it diers from the neutral position. Ask the patient to put their ‘chin on chest’ for forward exion—
this is usually about 75 degrees (but varies with age). Then ‘Look up at
the ceiling’ for extension, usually about 50 degrees. Assess lateral exion:‘Put your right ear on your right shoulder’ and the opposite for the
left. Look at the rise of the shoulder and compare sides. The range of
motion is usually about 90 degrees. Assess rotation:‘Put your chin on
your right shoulder’. This is just short of 90 degrees. Passive movement
is ver y useful but should only be done by experienced clinicians. This
can assess the static elements of the neck (ligaments, joint capsule) and
mobility motion (cadence of motion).
Power
Once you have assessed the control of the neck , assess the power of
the neck muscles in all the planes of movement:‘Push against myhand’.
Neurology
Comprehensive neurological examination of the upper and lower limbs
is required. Remember tone, power, sensation, coordination, proprioception, and reexes. Are the limbs held accid or is there a spastic
posture? Coordination and proprioception expose central pathology,
chronic alcohol abuse, infarct, metastasis, cord compression,etc.
Assessing a potential spinal injury patient
and imaging
As with any injured patient start with assessing Air way, Breathing, and
Circulation and addressing any issues encountered. Spinal assessment
falls at the end of D for disability, provided the spine has been immobilized, which should be done alongside the assessment of the Airway.
Unlike almost any other fracture (Look, Feel, Move, then X- ray),
when there is suspected trauma to the cer vical spine you may need to
imagerst.
EXAMIN ATION OF THE CERVIC AL SPINE
However not all cases need imaging. In some patient s, clinical exami-
nation alone may be able to ‘clear’ the neck. Commonly used guidelines
are the National Emergency X- Radiography Utilization Study (NEXUS)
Low- Risk Criter ia and the Canadian C- Spine Rules (or a combination
of both). Applying these will help determine the need for imaging. If a
patient does not full any of the criteria for imaging in the guidelines and
has only experienced low- risk factors then their collar can be removed
and the neck carefully assessed. Low- risk patients who can rotate their
head >45 degrees bilaterally should be considered not to have any signicant
spinal injury. Imaging is not required. However, if the patient cannot reach
45 degrees or has severe pain >7/ 10 or neurological symptoms, imaging is
required.
If imaging is required, plain lms or CT may be undertaken, depending
on the overall condition of the patient. If the patient requires a head or
thoracic spinal CT, the cervical spine is commonly included during this.
Otherwise plain lms may initially be taken. When plain lms are used,
the lateral view is particularly impor tant and this should be obtained rst
as par t of the initial radiogr aphic sur vey, along with a pelvic and CXR
(AT L S® protocol). Anteroposterior and odontoid peg views will also be
required. These are just guides. Always follow your hospital or local protocols.
Indications for cervical spine imaging following blunt forcetrauma
• If GCS score is<15.
• Patient is intoxicated.
• If patient complains of focal neurological decit, paralysis, or
paraesthesia in their arms orlegs.
• Patients with unexplained hypotension (systolic BP <90mmHg) or
hypo/ hyperventilation (respiratory rate of <10 or >24 breaths/ min).
• Urgent identication of C- spine injury is required (e.g. patient going
for su rge ry).
• Severe neck pain>7/ 10.
• Patient s with a high- r isk mechanism of injury and either severe
thoracic back pain >7/ 10 or visible injur y above the clavicles.
• Patient s with neck pain and any of the high- risk factors listed in the
nextbox.
105
High- risk factors for cervical spineinjury
• Age>65.
• Sustained a xial load to the head (e.g. diving).
• Fall >1 m or >5steps.
• MVC with combined speed of >65mph.
• Arollover MVC or ejection from a vehicle.
• AMVC involving recreational motor vehicles.
• Accident a s a cyclist.
• Injury sust ained over 48 hoursago.
• Re- attendance with same injury.
• Known spinal disease.
106
CHAP TER4 The back oftheneck
How to‘clear’ thecervical spine followingtrauma
‘Clearing’ a neck is more than just ruling out fractures. It also includes
ruling out ligamentous injuries. This requires more than simply looking
at a series of plain lms. The following is a guide only. This applies to
those patients in whom imaging is not indicated, based on the NEXU S
Low- Risk Criteria or Canadian C- Spine Rules (or a combination of both),
or in whom imaging has been t aken but it has not identied any fractures
or signs of soft tissue injury. However, always follow your local protocol
if available.
• Assess the neurological state of thelimbs:
•
Tone (lower motor neuron (LMN), damaged peripheral
nerve=accid; upper motor neuron (UMN) lesion=increased).
•
Po wer.
•
Sensation (sof t touch and pinprick).
•
Reexes (look for reduction or absence, compare sides).
•
Proprioception (posterior columns) and coordination should
ideally be included, but are probably seldom performed.
• Examine relevant imaging.
• Are there any other distracting injuries (especially head, neck,
thoracic, and upper limb injuries)?
• Ha s analgesia (opiates) beengiven?
• Is there any spinalpain?
• Is the patient mentally alert (head injur y, alcohol, drugs,etc.)?
If all the above are normal/ excluded, take the front of the collar o.
Instruct the patient not to move their head and ask an assist ant to support the head. Instruct the patient to keep their head very still and not
to nod or shakeit .
• Assess for spinal tenderness. A sk the patient to answer yes or no to
whether the area pressed is tender. Feel for any swelling, steps, or
crepitus.
• Assess active movement (i.e. ask the patient to move their neck— do
not move it yourself ). Lateral exion rst, then rotation, then lift
head o bed. Take your time— the neck will be a bit sti at rst if they
have been immobilized for sometime.
If the patient complains of any neurological symptoms or pain, the neck is
not cleared — replace immobilization and refer. Consider also the mechanism of injury and the possible need to image the entire spine. If the
patient can move their neck freely without pain or neurological symptoms then the neck has been cleared and the collar can be removed.
Advise the patient to infor m if symptoms develop.
EXAMIN ATION OF THE CERVIC AL SPINE
Assessment ofknown spinal- injured patient
When a spinal cord injury is identied, the patient must be immobilized,
and transferred carefully. Afull neurological examination should be carried out. Assess and record each of the following:
• Tone:by passively moving the arms and legs. Tone can be increased
in UMN lesions, or reduced in LMN lesions, i.e. damaged peripheral
nerves. Aspinal injur y can produce a mixed picture.
• Power:each individual myotome should be tested. The patient’s
eor t is graded on a scale of0– 5:
•
Grade 5:muscle contr acts normally against full resistance.
•
Grade 4:muscle strength is reduced but muscle contraction can
still move joint against resistance.
•
Grade 3:muscle strength is further reduced such that the joint
can be moved only against gr avit y with the examiner’s resistance
completely removed. As an example, the elbow can be moved
from full extension to full exion starting with the arm hanging
down at theside.
•
Grade 2:muscle can move only if the resist ance of gravity is
removed. As an example, the elbow can be fully exed only if the
arm is maintained in a horizontalplane.
•
Grade 1:only a tr ace or icker of movement is seen or felt in the
muscle or fasciculations are observed in the muscle.
•
Grade 0:no movement is observed.
(Medical Research Council (MRC) scale for muscle strength, ©
Crown Copyright.)
• Reexes:look for reduc tion or absence, by comparing both sides.
Reexes can be hyper reexic in UMN lesion, or reduced in LMN
lesions. An upgoing (extensor) Babinski reex is a sign of a UMN
lesion. There can be a mixed picture in spinal cord injuries depending
on the nerves or tr acts damaged.
• Sensation:pain (pinprick), temperature (spinothalamic tract), ne
touch, and proprioception (dorsal column).
Neurological injuries
These can be consideredas:
• Completeor
• Incomplete.
Or anatomicallyas:
• Anterior cord syndrome (motor function lost but sensation is
preserved).
• Posterior cord syndrome (seldomseen).
• Central cord syndrome (upper limbs aected more than lower).
• Brown- Séquard syndrome (ipsilateral loss of motor and
propr ioception, with contralateral loss of pain and temper ature
sensation).
107