1
Q
What are the risk factors for chronic RS? (5)
A
Deviated septum Tooth infection GERD Vitamin D deficiency Aspirin intake
Notes:
- The risk is increased with the severity of septum deviation.
- Infection of maxillary molars can provide portal of entry.
- Reflux esophagitis can be linked with chronic RS.
- Direct relationship between vitamin levels and degree of mucosal damage in sinuses and bone disease
- Aspiring acts as Sx trigger
2
Q
What are the cardinal clues for rhinosinusitis (RS)?
A
Sudden onset on Sx often occurring after short course of rhinitis (several days) and consisting of: PODS
D or O
P or S
1) discharge OR obstruction (nasal)
AND
2) pressure OR smell (loss)
3
Q
What are other additional Sx that may be present with RS?
A
Local ENT sx: sore throat, hoarsenEss, foul breath, nasal speech
Fullness in ears and maxillary toothache
Periorbital edema
Drainage may provoke Sx mimicking lung conditions: wheezing, coughing
General constitutional signs and Sx: fever, fatigue, malaise, irritability.
Chronic RS: Fatigue, poor sleep quality, depression, lower quality of life.
4
Q
What physical exam procedures should be done on a patient with RS? Which PE is the most predictive of this condition?
A
Observe Vitals (temp, pulse, BP, respiratory rate) Percuss/transilluminate sinuses** Rhinoscopic exam Examine pharynx Tap maxillary teeth Palpate lymph nodes Examine cervical muscles and joints Screen TMJ Perform otoscopic exam (children) Lung auscultation (if indicated) Cranial nerves II to VI (if indicated)
**transillumination has been described as “highly predictive of disease” with 90% sensitivity for frontal sinuses
5
Q
What are the 3 cardinal Sx of bacterial RS?
A
Purulent(infected, colored, oozing) nasal drainage
Nasal obstruction
Facial, dental pain
6
Q
How do you differentiate 1) simple rhinitis from 2) acute (viral) RS vs 3) chronic RS?
A
Duration is key:
1) simple rhinitis = 2-3 days, mild Sx
2) viral RS = 4-7 days, mild to moderate Sx that peak 2-3 days after onset
3) bacterial RS = >10 days w/ possible “double sickening” around day 5, very severe Sx
7
Q
What would a basic conservative care plan look like for acute RS?
A
- Watchful waiting
- First line Tx: Saline irrigation. Intranasal corticosteroid sprays. Analgesics.
- Manual therapy: spinal manipulation, sinus percussion/lymph drainage, argyrol Tx, steam inhalation, antibiotic
8
Q
What would a basic conservative care plan look like for chronic (8-12+ weeks) RS?
A
With Nasal polyp
- 1st line: Saline irrigation. Referral for intranasal corticosteroid sprays. Analgesics.
- Option: manip, spinous percuss/lymph, referral for macrolides, argyrol, low salicylate diet
WithOUT nasal polyp
- 1st: saline irrigation, intranasal corticosteroid sprays, nasal specific therapy.
- Option: Manip, sinus percuss/lymph drain, referral for macrolides, argyrol, steam inhalation
If no improvement in 4-6 weeks: CT/endoscopy, Tx with macrolides and/or brief course of oral corticosteroids.
9
Q
What in office interventions are most likely to promote drainage in chronic RS?
A
Nasal specific or argyrol applications may be useful to promote adequate drainage
10
Q
What home care interventions are most likely to promote drainage in chronic RS?
A
Nasal lavage (in office and home care)
11
Q
Which OTCs are most likely to be effective for RS:
Decongestants
Steroid sprays
Acetominophen cough syrups
A
Acetaminophen or OTC NSAIDS may help relieve P or fever in acute RS or chronic viral RS.
Notes
- Decongestants have short term effect on Sx of common cold, but do not affect sinuses
12
Q
Which of the following interventions have the most evidence: steam inhalation, auto-inflation for the ear, nasal lavage, lymph massage?
A
Nasal lavage
13
Q
What ancillary studies are most likely to be done to make the Dx of chronic RS?
A
CT w/o contrast or endoscopy
14
Q
Mucosa thickening _____mm is consistent with sinus infection
A
> 5 mm
15
Q
How does the presence of polyps (multiple or singular) affect your management plan for chronic RS?
A
With Nasal polyp
- 1st line: Saline irrigation. Referral for intranasal corticosteroid sprays. Analgesics.
- Option: manip, spinous percuss/lymph, referral for macrolides, argyrol, low salicylate diet
WithOUT nasal polyp
- 1st: saline irrigation, intranasal corticosteroid sprays, nasal specific therapy.
- Option: Manip, sinus percuss/lymph drain, referral for macrolides, argyrol, steam inhalation
If no improvement in 4-6 weeks: CT/endoscopy, Tx with macrolides and/or brief course of oral corticosteroids.
16
Q
What are the risk factors for AOM? (9)
A
Bottle feeding and pacifier use Smoking Daycare Socioeconomic factors Winter months Craniofacial distortions (FAS, trisomy 21) Diary Allergies Lack of vitamins
17
Q
What are the criteria for “certain” AOM?
A
Rapid onset
Presence of middle ear effusion
Signs/Sx of middle ear inflammation
18
Q
In what critical ways is AOM different from OME?
A
Only AOM has acute oneself of signs/Sx
AOM <48 hours
OME is chronic onset
19
Q
How long is watch and wait period for AOM? For OME?
A
AOM: 48-72 hours/2-3 days
OME: 3 months
20
Q
What PE finding suggest the presence of middle ear effusion? What is the most accurate in-office test?
A
- Limited or absent mobility of tympanic membrane (Dx by pneumatic otoscopy)
- Opacification w/ or w/o erythema
- Full, bulging, swollen tympanic membrane
- Hearing loss
Pneumatic otoscopy
21
Q
What PE procedures should be done in the case of a patient with ear pain?
A
Otoscopic exam to view tympanic membrane
Check vitals
Evaluate for pain referral
- TMJ
- CN V, VII, IX, X
- MFTP in Lateral and medial pterygoid, masseter, SCM
- Tonsillitis
- pharyngitis
- carcinoma of hypopharynx, larynx
- cleft defects
22
Q
What would a basic conservative care plan look like for AOM?
A
- Watchful waiting 48-72 hours
- In office: affect Eustachian tube, endonasal technique and auto inflation
- Optional: manip, STM, teach self lymph drainage
Do not do watchful waiting for someone <12 yo with a fever >102˚, severe illness or complications
23
Q
What are the 4 most likely causes of referred pain to the ear when the ear itself is not the pain generator?
A
TMJ syndrome
Dental causes
Tonsillitis or pharyngitis
Cervical spine syndrome
24
Q
What are the indications to refer someone for antibiotics if they have AOM?
A
Less than 12 yo, fever >102˚ F, severe illness or complications
25
What characteristics of a patient’s hoarseness would lead you refer for a medical workup?
No recent or current sickness
If it is chronic in nature (not acute presentation)
If they are older
*concerned that there is a tumor affecting the recurrent laryngeal nerve
26
Doing a PE on a patient with suspected infection anywhere in the head should always include which 3 assessments?
Take temp
Inspect throat
Palpate lymph nodes
27
What cluster of 4 signs/Sx suggest that a sore throat may be d/t strep?
ACAFE: 3 (+) and 1 (-)
```
A -age
<15yo = +1 point
>45yo= -1 point
C -coughless - NO Cough
A -adenopathy (tender anterior cervical lymphadenopathy)
F -fever
E -exudates (tonsillar exudate)
```
28
What are the Sx associated with glaucoma?
- >50 yo
- Blurred vision, haloes around lights
- Eye pain
- HA
29
What are the three most common causes of chest pain?
LC reason?
```
MSK e.g. costochondritis
Nonspecific chest pain
GI disease
Stable CAD
Psychosocial/psychiatric disease
```
LC: unstable CAD
30
What is the prevalence of acute coronary syndrome in a walk in primary care office?
1.5% or 1.5 patients out of 100
31
What indicators should trigger a call for ambulance for a patient with chest pain?
Chest pain plus respiratory distress or abnormal vital signs including erratic pulse or low BP
32
What associated Sx should you ask a patient with chest pain?
```
Confusion
Restlessness
Combo of dyspnea, palpitations, sweating
N/V
Weakness/fatigue
(Near) syncope
```
33
Which Sx have the highest LR for an MI?
History
i. Nausea (+LR 10)
ii. Both arm P (+LR 9.7)
iii. R arm P (+LR 7.3)
PE
i. 3rd heart sound (+LR 3.2)
ii. Hypotension (+LR 3.1)
iii. Pulmonary crackles (+LR 2.1)
34
MFTPs in what muscles are most likely to mimic the pain associated with cardiac angina?
Scalenes
Pectorals
Serratus anterior
35
What steps are involved in using Prilosec to test a patient to see if they have GERD?
High-dose PPI (proton pump inhibitor e.g. Omeprazole 40 mg b.i.d.) 2x/day in patients woh
- do NOT describe typical reflux
- have NO Hx of surgery in upper GI, esophagus, thorax
- have NO signs/Sx that indicated serious/malignant disease
36
What are the top 3 clues that would suggest that a patient’s chest pain is not cardiac in origin? And which one is the best clue?
Pain that is: pleuritic, positional, palpationable
Pain that is reproducible with palpation is the best clue
37
What special ancillary tests are options for the initial round of testing patients for cardiac angina? Which one is gold standard?
12 lead Resting EKG
Stress test (EKG, stress echocardiogram, myocardial perfusion scintigraphy)
Chest radiography (optional)
Angiography ** 🌟 gold standard
38
What are the 3 types of stress tests when testing for a patient with cardiac angina?
EKG
Stress echocardiogram
Myocardial perfusion scintigraphy
39
How does the CAC test fit into a cardiac assessment?
Coronary artery calcium (CAC) test checks the degree of calcification (amt of calcium) of the coronary artery.
This is a special CT scan, NOT blood test.
More calcium = more risk.
40
What blood tests are ordered to assess risk factors for coronary artery disease?
Lipid profile
Glucose/Hgb A1C
hsCRP
Remember CAC is NOT on this list because it is NOT a blood test.
41
What are other risks for CAD derived from the patient’s Hx and PE?
```
Male > F
Overweight or obese
LDL cholesterol >130 mg/dL
Physically inactive
HDL cholesterol <40mg/dL
Tobacco use
Metabolic syndrome
Prehypertension diabetes mellitus
```
42
What tests are done in the ED to Dx an MI?
12 lead EKG
Troponins
Cardiac enzymes
43
What is the classic triad of findings that suggest typical angina?
1. Substernal chest discomfort with characteristic quality and duration
2. Provoked by exercise or emotional stress
3. Relieved by rest or nitroglycerin
44
Be able to recognize the presentation of a patient with angina, pericarditis, valvular disease, pleuritis, MI. Know what follow up tests should be ordered for each.
Angina (3 Sx and 3 ancillary)
Typical angina Sx:
1- substernal chest discomfort
2- provoked by exercise/emotional stress
3- relieved by rest/nitro
Ancillary studies:
1- 12 lead resting EKG
2- Stress tests (EKG on treadmill, stress echo, myocardial perfusion scintigraphy)
3- Angiography 🌟
45
Be able to recognize the presentation of a patient with angina, pericarditis, valvular disease, pleuritis, MI. Know what follow up tests should be ordered for each.
pericarditis (3, 1)
Sx:
1- non-pleuritic friction rub (crackling sound like rubbing hair on pinnae of ear)
2- precordial pain that radiates to trapezius ridge
3- aggravated by supine relieved by bending forward
Ancillary study:
4- characteristic ECG/EKG echocardiogram changes
46
Be able to recognize the presentation of a patient with angina, pericarditis, valvular disease, pleuritis, MI. Know what follow up tests should be ordered for each.
Valvular disease e.g. aortic stenosis, mitral valve prolapse (1, 1)
Sx
1- mid systolic murmur or closing click
Ancillary
2- echocardiogram
47
Be able to recognize the presentation of a patient with angina, pericarditis, valvular disease, pleuritis, MI. Know what follow up tests should be ordered for each.
Pleuritis (ancillary studies - 5)
Sx: pleuritic pain, respiratory friction rub, fever/malaise
```
Ancillary:
1- chest radiograph
2- CBC
3- blood chem
4- ESR
5- ANA (because why not test for lupus)
```
48
Be able to recognize the presentation of a patient with angina, pericarditis, valvular disease, pleuritis, MI. Know what follow up tests should be ordered for each.
MI
Hx: nausea, both arm pain or just right arm pain
PE: 3rd heart sound, hypotension, pulmonary crackles
Ancillary studies
1- 12 lead EKG
2- troponins blood draws
3- cardiac enzymes CPK-MB which follows the same pattern as troponins but test not recommended anymore
49
How long do troponins take to show up in the blood? And when do they peak? And when are they gone?
2-3 hrs to show up
12 hrs peak
24 hrs disappear
50
What serious risk can arrhythmias subject a patient to?
Stroke or peripheral embolism
51
What are some common Sx associated with arrhythmias?
```
Irregularly irregular pulse
Tachycardia 110-140 beats/min
Palpitations
Fatigue
Dizziness
Angina
Decompensated heart failure
```
52
What % of arrhythmias are asymptomatic?
90%
53
What arrhythmias require urgent/emergent referral?
Lower chamber
54
What is the natural Hx of pain and disability for patients with typical neck complaints?
Favorable: 80-90% will resolve w/i 8 weeks
40% will relapse w/i 1 year
55
What are the Canadian/Nexus rules for when to order radiographs in trauma cases?
Hx - 7
PE - 3
History:
1. Age 65+
2. Dangerous MOI
3. Paresthesia in extremities
4. Painful, distracting injury elsewhere
5. Altered level of alertness
6. Evidence of intoxication
7. Patients w/known vertebral disease
PE:
1. Unable to actively rotate neck 45˚ to the left and to the right
2. Midline cervical spine tenderness
3. Focal neurologic deficit
56
What blood tests in a blood chem panel may point to a bone cancer? (And what kind?)
Alk phos = bone building disease
Ca2+ = bone breakdown disease
Protein = MM
57
How does syringomyelia present?
Diffuse “cape-like” distribution of pain/temp loss over 1 or 2 shoulders
58
What cervical conditions do oral corticosteroids put the patient at risk for? (2)
Osteoporosis
| Ligamentous (transverse ligament) instab especially in upper cervicals
59
How do you perform the arm squeeze test? How do you interpret it?
When there is NR compression, 1+ nerves of the arm are sensitive to moderate compression of the biceps and triceps area and should be more painful than other areas of the shoulder and upper arm.
A positive test hurts 3+ more (3/10 pain scale) or during the pressure on the middle third of the upper arm, compared with compressing the AC and anterolateral-subacromial areas.
Example: if shoulder hurt 1/10 but arm hurt 4/10 that suggests it may not be a shoulder problem, but a nerve problem that is from the neck.
60
What are causes of cervical radicular syndromes?
Break them into A-3, B-5, and C-3 lists
A list: osteophyte, disc hern, stenosis
B list: structural instab, tumor/sol, infection, NR adhesion, trauma to NR
C list: disc derangement, facet syndrome, joint dysfxn
61
Which one of these (A list: osteophyte, disc hern, stenosis) should you consider in trauma cases?
Disc herniation
Stenosis
**NOT osteophyte
62
What are a variety of neck mechanisms of injury that can directly damage a NR? (3)
How about mechanisms to damage the brachial plexus? (2)
NR: hyperextension, compression, lateral flexion w/shoulder depression
Brachial plexus: lateral flexion w/shoulder depression, arm traction
63
What are the various signs and symptoms of cervical spinal cord damage?
- P not common presenting sx
- Sx often vague and variable
- Clumsy numb hands
- Clumsy gait (stumbling, shuffling/stiff-legged, wide-base, Romberg)
- Lower ext- paresthesia, intermittent prox leg P, low back or mid-thoracic P
- 2/3rd pts w/ disc hern have bladder dysfxn (urinary freq, urgency, incontinence, retention)
- L’Hermitte sign (25%)
- Motor hand: intrinsic atrophy, finger escape sign, rapid open
- Abnormal reflex (+3 or 3), paradoxical reflex, clonus, pathological reflex
- Vibration diminished
64
What would a complete exam look like for cervical spinal cord damage?
Neck flexion (look for L’Hermitte’s sign)
CN exam
UE:
- Observe hand intrinsics
- Finger escape sign ( + the patient is asked to squeeze his/her fingers together (adduction) while extending them backwards with the wrist in neutral. A positive test occurs if the two ulnar digits “escape” into flexion and abduction within 30 seconds.)
- Rapid open and close (NOT Roos)
- Hoffman (dynamic) or clonus
- SMR including sharp, vibration/position sense** know how to do position sense
LE
- Gait/Romberg
- SMR: sharp, vibration/position
- Babinski/clonus
- Single leg stand
65
What are the MC causes of cervical cord compression? What are other causes?
Causes of Cervical myelopathy
A list-2
B list- 6
A LIST:
1- disc hern (<50-60 y.o)
3- stenosis (>50-60 y.o)
```
B LIST
1- Trauma (hyperflexion)
2- Structural instability
3- Tumor/SOL
4- Infection
5- Fx
6- Spinal cord adhesion
```
66
What interventions are contraindicated when managing cervical cord compression?
Cervical traction
| Adjusting
67
What are the various signs and symptoms for a cervical facet syndrome?
Palpatory:
- Tenderness over the facet
- Tissue changes around the joint
- Joint restriction
Joint loading:
- Local pain with active or passive extension
- Local pain with cervical compression
- Local pain with quadrant position or cervical Kemp’s
68
MOI for cervical facet syndrome?
Trauma (micro or macro)
Sustained postural loads
Simple activities of daily living (if neck is functionally unstable)
69
Based on a facet block study, what combination of findings were most predictive? Which of those findings carried the most weight in decreasing the probability of a cervical facet syndrome?
1 - (+)ve ER test >3/10 OPS
2 - Pain w/palpation over the facet >3/10 OPS
3 - Cervical restriction P-A joint glide
Most weight: palpatory ternderness
70
What are medical interventions for cervical facet syndrome?
Radiofrequency neurotomy
DEFINED:
medial branch of dorsal Ramos is enervated by coagulating and denaturing the proteins in the nerve. The nerve is not destroyed. This blocks the conduction of painful messages along the nerve to the DRG. The nerve may grow back to its target facet joint after 6-9 months and pain may return.
71
What are the “big five” orthopedic tests to diagnose cervical radicular syndromes?
Which one is more sensitive for this condition? Which ones (4) are more specific?
```
Cervical compression -SPEC
Cervical distraction -SPEC
Shoulder ABD -SPEC
Valsalva -SPEC
ULTT - median nerve **SEN
```
72
What is the peak age range for cervical disc herniations?
50-54 yo
| Rare <30yo
73
What are the MFTP referral territories for the scalenes, infraspinatus, supraspinatus, latissimus dorsi, serratus anterior and the pecs? What nerve root or peripheral neuropathies might each mimic?
Scalenes mimic C6 NR or radial n → lat arm (esp delt) and postlat thumb and index finger (snuff)
Supraspinatus mimic C6 or radial n→ Lat delt, ant palm & index, and post hand
Infraspinatus can mimic C6 or radial n→ go into lat hand
Lats mimic C8 or ulnar nerve→ down med arm to pinkie and ring fingers
Serratus ant mimic C8 or ulnar nerve→ down med arm to pinkie and ring fingers but extending more into palm
Pec minor mimic C8 or ulnar nerve→ down medial arm and into little finger
74
What are the signs and symptoms of a cervical disc derangement? Which one is more accurate? What findings would cast the most doubt on the Dx?
- Cervical discogenic referred P
- Deep referred arm P may be improved by rep end range movement into chin
retraction, extension, or some other direction→ STRONGEST
- Neck &/or chin retractions may be beneficial; neck flexion &/or chin protrusion may aggravate
- Less likely to have tenderness localized over facets
- May have (+)ve valsalva
- May be relieved by cervical distraction
- May be aggravated by cervical compression
Signs/Sx of neuro involvement would cast doubt on deranged disc.
75
What are the first directions to attempt when looking for a directional preference by repetitive or sustained cervical joint loading?
Protraction
Retraction
Extension
Flexion
76
What are the medical interventions for disc derangement? (2)
Intradiscal electro thermal therapy (IDET)
Percutaneous intradiscal radiofrequency thermocoagulation
77
What are the signs/Sx of CRPS? (Pain, Autonomic dysfxn, Motor dysfxn)
Pain: severe, burning, extremity, non-dermatomal, palmar/plantar dominance, allodynia/hyperalgesia
Autonomic dysfxn: swelling, tropic changes, sweating, altered skin temp
Motor dysfxn: hyperreflexia, tremor, muscle weakness, movement disorder, dystopia leading to contractures
78
In a patient with neck pain, but no evidence neuropathic involvement, what are the most likely pathoanatomical diagnoses?
```
Sprain
Strain
Facet syndrome
Disc derangement
Fracture, if traumatic
```
79
In a patient with neck and arm symptoms, what are the 5 broad diagnostic possibilities to consider regarding how the neck and arm symptoms are related?
```
Cord
Nerve Root
Peripheral nerve
Deep referred pain
2 Separate lesions
```
80
What indicators from the history or physical exam tend to be most accurate at predicting which cervical nerve has been injured?
Deficits and paresthesia distribution more predictive than P distribution (C6 or C7)
81
Which neurological deficits are most specific for each of the following nerve roots?
C6
REFLEX: decreased biceps or brachi-radialis reflex
Then sensory loss of thumb
Then weak wrist extension
82
Which neurological deficits are most specific for each of the following nerve roots?
C7
REFLEX: diminished triceps reflex
Then weak elbow extension
Then sensory loss of middle finger
83
Which neurological deficits are most specific for each of the following nerve roots?
C8
SENSORY: loss little finger
Then diminished triceps reflex
Then weak finger flexion
84
What are all of the key characteristics and features of nerve pain that you want to try to elicit from your patient with arm pain?
??
85
What pattern of physical exam procedures and their findings would suggest a nerve root that was most susceptible to compressive forces?
What pattern of PE procedures and their findings would suggest a nerve root that is more sensitive to tension forces?
CLOSURE
• AROM: extension, ips-rotation/lateral flexion aggravate
• AROM: flexion, contra-rotation/lateral flexion decreases arm Sx
• Cervical compression increases Sx
• Cervical distraction decreases Sx
TENSION
• ULTTs increase arm Sx
• Shoulder ABD/Bakody’s sign decrease Sx
86
What are the key indicators to order a cervical radiographic series?
* Moderate to high load trauma
* Red flag for disease
* Cord signs/sx
* Radicular sign/sx
* Non responsive cases
87
What are the indicators for when to order an MRI in a patient with a cervical disc herniation?
```
• Lowest: signs/sx of radiculitis
• Moderate: only with deficits
• Highest: **this is the bullet to memorize** “standard of care” for us as students
◦ suspicion of myelopathy
◦ progressive deficit
◦ non responsive to conservative care
◦ pre-surgical exam
```
88
What are the indicators for ordering an MRI other than related to a cervical disc herniation?
Cord damage
| Neuro deficits: mm loss of grade 3/5 or worse
89
If your patient has pain or paresthesia along the medial side of the hand (little finger), where in the nervous system might the lesion be?
What specific muscles with MFTPs might project pain into that area?
* Lower brachial plexus injury e.g. TOS, tumor, stretch trauma “plexitis or plexopathy”
* Ulnar nerve entrapment or nerve root “neuritis or neuropathy”
* Nerve root “radiculitis or radiculopathy”
* MFTPs: Latissimus dorsi, Serratus anterior, Pectoralis Major or Minor
90
If your patient has pain or paresthesia along the lateral side of the hand, where in the nervous system might the lesion be?
What specific muscles with MFTPs might project pain into that area?
• C6 nerve root
• Radial nerve entrapment
MFTPs: Scalenes, Supraspinatus, Infraspinatus
91
What are the key symptoms to ask a patient with neck pain who has just suffered an MVA?
* Head trauma? LOC (for how long?)
* Detailed accounting of the symptoms and injuries at the time of the accident and subsequent to the accident. Specific chronology. Include questions about vision, dizziness, dysphagia, etc.
* Detailed accounting of any previous examinations, diagnosis or treatment related to the accident. History may occur well after MVA in some cases.
* Past history of any MVA or cervical trauma. Any overlap in symptoms pre-and post.
92
What nerve roots control your forearm pronators?
C6 (or C7)
93
Explain how each of the following might test in the case of a cervical strain vs a cervical sprain:
AROM
sTrain: pain with muscle contraction
sPrain: maybe pain with initial movement
94
Explain how each of the following might test in the case of a cervical strain vs a cervical sprain:
pROM
sTrain: no pain
sPrain: pain at end range
95
Explain how each of the following might test in the case of a cervical strain vs a cervical sprain:
Resisted ROM
sTrain: painful
sPrain: painful at end range when the ligament is pulled
96
Explain how each of the following might test in the case of a cervical strain vs a cervical sprain:
isometric muscle test
sTrain: painful
sPrain: no pain
97
What are two things that a RUST sign might signal in a trauma case? (3 things really)
Describe Rust’s sign
fracture, instability, severe sprain
Rust’s sign: patient stabilizes head when moving from seated to lying
98
What are the 4 main components of a cervical stabilization program?
1. Eval and train deep neck stabilizers
2. Assess and Tx posture and respiration
3. Address mm imbalance of large torque producers
4. Retrain sensory motor response loop
99
What are the components of a “low index” neurological physical exam screen?
Sensory: do soft touch with doc’s hands for speed
Mm test: finger flexors, maybe deltoid
DTRs: triceps and biceps
100
Outline your treatment plan for TOS.
Adjust ribs, C-spine, upper T-spine, AC, SC, GH, scapulothoracic
Stretch PIR/CRAC/instrument assisted/pin-and-stretch/etc: scalenes, pec major, levator scap, suboccipitals, Pressure work on pec minor e.g. intermittent ischemic compression
Home exercise: stretch pecs and scalenes, neuromob
Activity/behavior mod: adapt job, find alternate ways to carry bags, correct forward head carriage, correct breathing patterns
101
What are the signs and symptoms of TOS?
- Dominant symptoms include shoulder and arm pain
- Paresthesia of the fingers (often the 4th and 5th digit)
- A sense of heaviness or fatigue in the arm
- Sometimes pallor in the fingers.
- Sensory symptoms generally cover more than one dermatome and precede motor symptoms.
- The hand may also demonstrate loss of grip strength, incoordination or clumsiness
- Other symptoms may include neck pain or headache.
- Symptoms are usually unilateral
102
What at the findings necessary to make a “true” neurogenic TOS diagnosis?
- Neuro signs dominate, often occompanied by little or no P
- Sensory loss typically ulnar aspect of hand/forearm
- Gilliatt-Sumner hand
MUST HAVE 1 of:
1. Reproducible neurological deficit seen it PE
2. Positive EMG-NCV study demonstrating plexus damage
103
What are the signs and symptoms of an arterial vascular TOS? What should you do?
* Unilateral cold sensation
* ‘Pallor of the fingertips
* Splinter hemorrhages
* Raynaud’s like phenomenon
* Asymmetrical decreased radial push
* Asymmetry of BP >20 mmHg (lower pressure in symptomatic arm)
* Subclavian bruits
* Mild signs of cramping or fatigue with repetitive use
* Sometimes Sx that suggest neurogenic compression
Refer out
104
What are the signs and symptoms of a venous vascular TOS? What should you do?
* Swelling in the hand or arm
* Non pitting edema
* Distended superficial veins in the UE and chest
* Cyanosis
* Ecchymosis sometimes with feeling of heaviness or fatigue in arm
*Refer to Urgent Care
105
Which muscles (2) are most likely to contribute to the entrapment of the brachial plexus in TOS patients? And what is 1 more reason that is not a muscle?
Ant scalenes
Pec minor
Costoclavicular compression
106
Neurovascular entrapment is thought to be caused by:
* compression of the brachial plexus, subclavian artery and/or vein at some combination of the following sites:
* interscalene triangle
* B/w first rib and clavicle
* B/w corocoid process and tendon of the pec minor muscle.
107
What are the key components necessary to make a T4 syndrome diagnosis?
Joint dysfunction around T4
| Glove paresthesia in upper extremity
108
What are other symptoms/signs that may also be present in T4 syndrome?
What usually are the results from a neurological examination?
May wake up at night w/ sx or worse in the morning
Raynaud’s syndrome
Helmet HA
Results from neurological exam are WNL
109
What is Schepelmann’s sign? What does it mean?
Procedure: patient seated arms fully abducted and raised over head. Instruct patient to laterally flex thoracic spine to the L side and then to the R
(+) pain on the concave or convex
• Pain on concave = intercostal neuritis while
• Pain on convex = fibrous inflammation of the pleura OR intercostal myofascitis
110
What is Beevors’ sign? Where could the neurological lesion be?
Supine patient is asked to crunch up. Beevor’s test is a muscle test for NR or myelopathy.
Myelopathy: umbilicus deviates upward
NR: deviates away from side w/NR lesion
111
What is an abnormal superficial abdominal reflex? Where could the neurological lesion be?
Scratch the skin in the 4 quadrants of the skin around umbilicus
Normal response: umbilicus deviates toward stimulation
Abnormal response: no movement suggests UMNL
Unilateral absence: LMNL
112
What are the locations on the back for pain referral from the:
Gallbladder?
GERD?
Pancreas?
Ulcer?
Gallbladder: R inferior angle of scapula OR up to the R shoulder
GERD: center of back between shoulder blades
Pancreas: TLJ
Ulcer: left mid back/flank from inferior border of scap and downwards
113
What are three organ systems noted for referring pain into the thoracic spine area?
GI
Heart
Lung
114
What physical exam procedures are recommend to screen GI, Heart, Lung systems?
GI: palpate abdomen, gallbladder, pancreas
Heart: auscultate heart
Lung: auscultate lungs
115
What type of repetitive motions can put the thoracic spine and ribs at risk for injury?
- Forward head carriage
- Push/pull activities
- Rotational activities
116
What are common causes of thoracic nerve root lesions? (3)
Causes of intercostal nerve lesions? (3)
Causes of thoracic spinal cord lesions?(3)
NR: stenosis, tumor, disc herniation
Intercostal nerve: Trauma, neuritis, shingles
Thoracic cord: Stenosis, tumor, disc herniation
117
What is a DDX for thoracic trauma cases?
```
Sprain/strain
Facet syndrome
Disc derangement
Costovertebral sprain
Rib Dx
Intercostal strain
Spinal Fx
Contusion
```
118
What is a DDX for non-traumatic thoracic cases?
```
Scapulocostal syndromes (snapping scapula)
Thoracic joint dysfunction
Rib joint dysfunction
Facet syndrome
Disc derangement
Postural sprain/ syndrome
Intercostal/scapular MFTPs
```
119
What diagnoses can be associated with the ribs?
Fx
Sprain
Joint dysfunction
120
What are three lungs conditions associated with pleuritic pain? What are some musculoskeletal conditions associated with pleuritic pain?
Lungs: pleuritic, pulmonary embolism
MSK: rib (Fx, sprain, joint dysfunction), Tx (Fx, sprain, joint dysfunction), intercostal muscle (strain or spasm)
121
What are two special exam procedures to help detect cervical dorsalgia?
Doorbell sign = P b/w shoulder blades
Rotation w/passive over pressure into extension may reproduce thx pain
122
How common is herpes zoster?
1/4 people
123
What is its natural history of how it presents and how long it lasts?
* Early signs: itching, tingling, then pain 1-5 days before blisters
* Rash: 7-10 days
* Complete healing: 2-4 weeks
124
What are the key medical treatments for treating and preventing both herpes zoster and post herpetic neuralgia?
* Relieve itching: Calamine lotion
* Medical Tx: paracetamol, ibuprofen, codeine
* Acyclovir w/i 72 hours. 800 mg orally 5x/day for 7-10 days
* >50 yo consider vaccine for prevention
125
What are the radiographic changes consistent with Scheuermann's disease?
Calcification of vertebral ephiphyses:
A. Notching of vertebral endplate
B. Wedging of vertebral bodies
126
What is the measurement cut point for hyperkyphosis in Scheurmann’s disease?
40-45˚
127
What is the measurement cut point for recommending surgery for Scheurmann’s disease?
>65˚
128
To screen for spinal cord involvement, what neurological exam procedure would need to be done in the lower extremities.
* DTRs
* Pathological reflexes
* Superficial ab reflexes
* Presence of hypertonic
* LE sensory
* Mm weakness
* Altered sphincter fxn
129
What are two ways to test to see if the hyperkyphosis of Scheuermann’s disease is rigid or not?
* lie supine on a bolster/foam roller placed under apex of deformity
* see if they can bend over
130
What are three separate clinical scenarios (i.e., types of patients) in which to suspect a thoracic compression fracture?
Trauma: sudden pain + snapping audible
>70 yo Spontaneous compression Fx
>50yo osteoporosis
131
What types of loads/positions might tend alleviate compression fracture pain?
What might aggravate it?
Alleviate: Rest or lying down
Aggravating: Standing, walking, activity
132
What is paralytic ileus? What tends to cause it? How is it managed? What is its natural history?
Temporary stoppage of intestinal peristalsis 2-3 days caused by compression Fx
Manage: food fast 2-3 days
133
Explain the type and timing of ancillary studies in suspected rib fractures.
Radiographs: AP and lateral NON-displaced Fx may not show up for 3 weeks (if you can’t wait 3 weeks, CT will show up immediately)
134
What are Smorl’s nodes? Are they usually symptomatic?
thoracic IVD herniate through endplate, usually asymptomatic. But inflammatory, foreign body type Rxn can occur
135
What structures are the usual causes of pain in scapulocostal syndromes?
Irritation to soft tissues contained w/i scapular interspace
• Subscap mm
• Decreased viscosity of serous fluid minimizing friction in the interface to lubricate the movement
136
What does the SICK acronym stand for?
Scapular malposition
Inferior/bridal border winging
Coracoid tenderness
dysKinesis
137
About what percentage of low back pain cases may be serious diseases like cancer or spinal infections?
3% d/t serious disease
• 1% cancer, infection
• 2% is deep referred P
138
What is the natural history of low back pain related to pain and disability over the course of a year?
90% LBP resolves in 3 weeks
33% of patients experience mod or intense pain at 1 year
20% reported functional limitations in long term >1 year
139
What is the reported prevalence s of each of the following causes of chronic LBP:
• disc injuries
• facet syndrome
• SI injuries
Disc 40%
Facet 5-60%
SI 20%
140
What are key clues from the history and physical exam to support a lumbar facet syndrome?
Which of the clues would help differentiate it from a disc derangement?
```
Hx: >50 yo
PE:
• Extending up from flexion
• Active hyperextension
• Passive extension (e.g. prone extension test)
• Extension + Rotation —> Kemps
• Tenderness over facets with palpation
• motion palp reveals painful restricted joint
```
Dx from disc:
- Pain centralization w/ repetitive or sustained spinal loading suggests disc over facet
141
Which would be the strongest clues against a facet syndrome? (5)
Pertinent negative: negative kemps is better against facet syndrome than a kemps will support it.
Lack of improvement with recumbency
Evidence of radicular syndrome
Valsalva maneuver is negative, but can be positive in acute cases
Flexion biased loading tests
142
What are three different positive results from doing repetitive spinal loading that would suggest that you found a directional preference?
Decreased pain territory
Decreased severity of distal pain or paresthesia
Increased AROM
143
What are the roles of radiographs, MRI and discography in diagnosing lumbar disc derangements?
Imaging not indicated unless more aggressive Tx needed
Xray, dynamic views, CT
MRI reveals annual tears
144
What is the most common positive exam finding in patients with spondylolisthesis?
Step off defect test
145
What muscles are most commonly in need of stretching for spondylolisthesis?
Hamstrings
146
How common is it to have a positive SLR or neurological deficits in spondylolisthesis?
SLR rarely positive
| NR deficits not common
147
What are the imaging choices for confirming a spondylolysis diagnosis?
What are the advantages and disadvantages of each?
Radiograph is initial imaging
CT is best for occult spondy but high radiation, and don’t know if its active or inactive
SPECT 🌟 for active occult but high radiation
MRI
148
What are the most common pain referral patterns for Maigne’s syndrome (TLJ syndrome)?
Follows cluneal nerves (gluteal) to SI joints
149
How does a psoas syndrome differ from a psoas myofascial pain syndrome?
Psoas syndrome the TLJ is pain generator vs psoas being pain generator in a MFPT
150
What are the pain referral patterns for psoas syndrome (2) vs psoas myofascial pain syndrome (3)?
Psoas syndrome = TLJ joint dysfunction = P referred to iliac crest and buttock
Psoas MFTP: paraspinals, anterior thigh, iliac crest
151
What is the treatment program for psoas syndrome vs psoas MFTP?
Psoas syndrome
- in office: adjust TLJ, stretch/relax psoas
- home: psoas stretch, TLJ self mob
Psoas MFTP
-in office: treat the trigger point
152
What is the pain referral pattern for a QL myofascial pain syndrome? (4)
Greater trochanter
SI joint
Ischial tuberosity
Iliac crest
153
When performing the prone extension test, what are the various possible findings and what do they mean?
LBP aggravated by resisted ext → extensor strain
LBP aggravated by passive overpressure → Lumbar joint (facet, disc derangement, sublux, sprain, spondylolisthesis)
LBP w/ hypermobility → segmental instability
Leg sx aggravated in pts >55 (sustained) → spinal stenosis, osteophytic root compression
Leg sx centralize w/ repetition → disc lesion (deranged or hern)
154
What are the signs and symptoms of cauda equina syndrome? (Indicate which sx is MC)
Urinary retention — MC
Incontinence
Paresthesia in saddle distribution
Altered anal sphincter tone
155
What do you do next if you get a hard positive SLR in a patient with low back and leg pain?
Hard (+) SLR confirm with Braggard, Bowstring, Bonnet
156
What do you do next if you get a soft positive SLR in a patient with low back and leg pain?
Soft (+) SLR do Max SLR and/or Seated SLR
157
What do you do next if you get a hard or soft positive Bechterew’s test in a patient with low back and leg pain?
Hard (+) Bechterew: confirm with Bragard, bowstring, bonnet
Soft (+) Bechterew: confirm with slump test
158
If you got negative tension test, what do you do?
Go right to max SLR
159
What are extra spinal causes of sciatica?
DDX list
• Piriformis syndrome
• Pelvic/gynecologic conditions (including endometriosis**)
◦ **tissue can wrap around sciatic nerve. May get sciatica when this female has her menses and the tissue is engorged with blood.
• Herpes zoster
• Diabetic neuropathy
• HIV/Lyme disease neuropathy
• Pregnancy/delivery (prolonged time in lithotomy position)
• Trauma to nerve or surrounding structures (hip/pelvis/biceps femoris)
160
What is the most common age range for lumbar disc herniations?
30-55yo
161
What combination of clues would support a lumbar disc herniation?
Discogenic clues:
◦ Sx centralization with repetitive/sustained loading *,**
◦ Decreased sagittal thoracolumbar ROM*,**
◦ Positive Valsalva*,**
◦ Sitting poorly tolerated*,**
◦ DeJeurine’s triad*,**
◦ Flexion load sensitivity*,**
◦ Sensitive to axial loading (e.g., dSLR) *,**
◦ Positive XSLR (well leg causes bad leg P) *
◦ Mannequin sign*
* herniation
* *derangement
162
Which is the single most specific clue for a lumbar disc herniation?
Positive XSLR (well leg)
163
What was recommended in lecture as your early intervention package of interventions for a lumbar disc derangement? (4)
* HVLA manipulation (OV)
* Flexion-distraction therapy (OV)
* Directional preference exercises (home-based)
* Hip hinge/Neutral pelvis/abdominal bracing (behavioral modification)
164
What was recommended in lecture as your post-acute intervention package of interventions for a lumbar disc derangement? (2)
* Lumbar stabilization rehab (home-based or supervised; when patients can sit comfortably?)
* Neuromob procedures (OV & home based sliders/tensioners)
165
What are the 2 clinical presentations of lumbar spinal stenosis?
1. Neurogenic claudication “lumbar spinal stenosis with neurogenic claudication”
2. Radicular/sciatica “lumbar spinal stenosis with sciatica”
166
What are some of the key signs and symptom that would suggest lumbar spinal stenosis?
• >60 with neurogenic pain
◦ Made worse by extension: walking, standing, hyperextension
◦ Made better by flexion: sitting, walking uphill, squatting
• Wide gait +LR 13
• Improved walking tolerance w/ spinal flexion -LR 0.5
• “Heaviness” or “tired legs”
• Paresthesia, odd sensations, usually non-dermatomal
167
What are some of the key differentiating features between neurogenic and vascular claudication?
Neurogenic/Stenosis:
- Location: thighs
- Increased mm weakness after walking.
- decrease P bending over
- increases P walking downhill/increased lordosis
- LE pulses will be present
- Shopping cart sign will be present
PAD/vascular claudication
- Location: lower leg MC
- unchanged after walking
- decrease P sitting, stopping
- increase P walking uphill, increased metabolic demand
- LE pulse absent
- Shopping cart sign absent
168
What conditions are suggested by a positive Kemp’s test that aggravates leg symptoms?
True (+)
- IVF encroachment: osteophyte/spurring, IVF stenosis, disc hern
(+) Local P
- joint lesion: facet/lig/disc lesion
- facet
(-) kemps is better clue against facet syndrome. “Pertinent negative”
169
What are key clues from the Hx that would suggest lumbar functional instability?
Hx
• episodic nature triggered by trivial events
• Reports of catching, locking, giving away
• Immediate pain with sitting
• Temporary response to manipulation
• Decreased response to manipulation over time
170
What are key clues from the PE that would suggest lumbar functional instability?
PE
• Altered quality of movement (e.g. painful arc)
• Specific segmental findings (e.g. positive prone instab test, decreased resistance with prone joint play)
• Evidence of poor motor control (e.g. poor motor control during single leg stand, segmental abnormal movement)
171
What is the proposed clinical decision making rule for identifying patients that would benefit from a lumbar stabilization program?
<40 yo
Ave >91˚ flexion in both legs SLR
Positive prone instab test
Aberrant movement with lumbar flexion
172
In hip conditions, what is the “C” sign?
When the patient cups their hand over their greater troch and says that’s where the pain is.
173
In hip conditions, where is the most common location of the pain at least initially?
- MC location groin (84%)
- Buttock (76%)
- Ant thigh (59%)
- Post thigh (43%)
- Must ddx from knee lesion ANT Knee (69%)
- Shin (47%)
- Calf (29%)
174
In hip lesions, which muscle is most likely to go into spasm?
?
175
What is the log roll screen?
Pt lies supine
| Doc place one hand at knee, one at ankle and roll leg internally and externally
176
What are a couple of other signs that suggest that the hip may be the source of the patient’s pain?
P aggravated with weight
Associated with pain and decreased IR
(+) anvil test, circumspection, Faber, hip scouring
Assess active and pROM as well
Limp, groin P, limited hip IR = predictive of hip disorder than spine disorder
177
According to a small 2004 study, what combination of 3 findings are most helpful at differentiating hip pain from lumbar pain?
Limp
Groin P
Limited hip IR
Suggestive of hip (NOT spine)
178
What are 4 local causes of lateral hip pain?
Gluteus medius tendinopathy
ITB tendinopathy
Trochanteric bursitis
External snapping hip (ITP/Glute max)
179
What causes an external snapping hip syndrome? Internal snapping hip?
External: ITB/Glute max
Internal: iliopsoas
180
What were two exam findings that most strongly support a diagnosis of g medius tendinopathy?
- lateral hip pain w/ single leg stand <30 sec
| - resisted Fader test
181
What are 5 intracapsular causes of anterior hip pain? What are 2 extracapsular causes of anterior hip pain?
Intracapsular:
- Hip OA
- FAI (femoroacetabular impingement)
- Labral tear
- AVN
- Stress fx
Extracapsular:
- Adductor tear
- Internal snapping hip (e.g. iliopsoas)
182
What are the 4 seronegative arthropathies?
Psoriatic arthritis
Ankylosis spondylitis (AS)
Reiter’s syndrome
Enteric arthritis (UC, Crohn’s disease)
183
What are 5 screening questions for AS?
```
Morning stiffness?
Improves with exercise?
Onset pain before 40 yo?
Slow onset?
Pain persisting > 3 months?
```
184
What 6 tests are recommended to perform on a patient to see if they have SI pain? Which 5 should be interpreted as a group? What is their combined +LR?
ASLR
```
Thigh thrust
Sacral thrust
Gaenslen’s
SI compression
SI distraction
```
3+ (+)ve tests = LR 4.1
185
There are 6 tests recommended to perform on a patient to see if they have SI pain:
ASLR
```
Thigh thrust
Sacral thrust
Gaenslen’s
SI compression
SI distraction
```
3+ (+)ve tests = LR 4.1
What other findings can raise the +LR to 6.9?
No centralization with repetitive movements
186
What two pieces of information does a positive active SLR tell you?
- Suggests the SI joint is the pain generator
| - possible SI functional instability
187
What should you immediately do if it the active SLR is positive for pain when you are performing the test?
Retest with abdominal bracing, or trochanteric belt (preggo)
188
What are three conditions associated with the piriformis?
* Spasm
* Syndrome
* Myofascial pain syndrome
189
What are some important contributions to an SI problem?
* Sacroiliac muscle imbalance pattern
* Lower cross syndrome
* Tight hamstrings
* LLI
190
What muscles are inhibited/short in a dysfunctional Sacroiliac muscle imbalance pattern as suggested by Janda?
◦ Ipsi glut max inhibited
◦ Ipsi iliopsoas short and tight
◦ Ipsi piriformis short and tight
◦ Contra glut med inhibited
191
What are the two different neurological presentations of lumbar spinal stenosis? (Which one is MC?)
* Neurogenic claudication - MC
| * Radicular/sciatica
192
What are some of the clues that would support each of these two different designations: neurogenic claudication stenosis vs radicular/sciatica stenosis?
Neurogenic claudication:
- leg P with walking
- leg P sensitive to spinal position
Radicular:
- leg P unrelated to body position
- unilateral or bilateral leg pain
- may occur alone or w/neuro claud
193
It is convenient to organize the various signs and symptoms of stenosis into MECHANICAL clues and NEUROLOGICAL clues. Cite three examples from each category.
Mechanical clues
- pain with walking
- flexion relieves
- extension makes it worse
Neurological clues
- proprioception/balance affected
- basic neuro: SMR deficits 50% of the time (rarely +ve SLR)
- rarely CES present
194
Besides leg pain, how else might a stenosis patient describe their leg symptoms?
“Heaviness,” “tired legs”
| Paresthesia, “odd sensation,” usually non dermatomal
195
Are the extremity Sx more commonly unilateral or bilateral in stenosis?
Bilateral
196
When there are bilateral symptoms in stenosis, is this due to cord involvement?
unlikely
197
Diagnosis of spinal stenosis is contingent on what 3 factors?
- Signs and Sx
- Radiographic evidence
- R/o other back and leg causes
198
Cite 5 competing causes of lumbar radicular syndromes other than stenosis.
* Lumbar disk hern
* SOL
* Osteophytes NR compression
* Compression Fx
* Spinal infection
199
Cite 5 peripheral nerve causes of sciatica in an older patent.
* Piriformis syndrome
* Diabetic neuropathy
* Herpes zoster
* Compartment syndromes
* Peroneal nerve compression
200
What is the sequencing for ordering ancillary studies in a suspected lumbar stenosis case?
Xray
MRI/CT
Electromyographic paraspinal mapping
201
What is the role of electromyographic paraspinal mapping?
Surgery
It maps the involved muscles and checks what degree the nerve potentials are being affected
202
What are the initial ancillary tests of choice for a suspected PAD case? What is the gold standard test?
Duplex/Doppler US
Ankle-brachial index
Magnetic 🧲 resonance angiography 🌟
203
How and when does a treadmill test fit in?
When you need to DDX leg pain from stenosis vs PAD
- Stenosis patients can walk further uphill (because spinal flexion relieves)
- PAD patients cannot walk as far (because increased mm oxygen demand)
204
What would be some components of a conservative care program for PAD? (3)
- Walking ‘near pain threshold’ at least 3x/week
- Lifestyle changes: stop smoking, improve diet
- Toe raise 3x/day
205
Using the 4 block “main tool boxes” for treatment, outline various treatment approaches for lumbar stenosis.
* CMT: joint manipulation/mob, flexion-distraction therapy
* STM: PIR, IASTM, treat any spasm or MFTPs
* Activity Mod: avoid prolonged standing, avoid arms overhead
* Exercise: flexion-based exercises, core stab exercises, walking program
206
What are some additional aides or supports that could be recommended to the stenosis patient? (3)
Lumbosacral corset: improve walking distance
US: 5 sessions/week for 3 weeks
Wheeled walker: improve P and walking distance
207
Explain what we know about prognosis for spinal stenosis.
Not as good for disc hern, non-specific LBP or spondylolysis or -listhesis
😊 30-50% of cases of mild-mod stenosis are favorable w/o Tx
😊👩🏻⚕️ 50-70% treated non-surgically
👩🏻⚕️💉 20-40% will have surgery eventually
208
What are medically-based options for the stenosis patient if usual conservative care does not work?
- Epidural transformational steroid injections
- Surgical decompression w/ or w/o lumbar fusion
- Lumbar decompression
209
What are indications for surgery for stenosis?
- Severe leg P
- Significant difficulty walking
- progressive neuro loss
- CES Sx (bowel or bladder dysfunction)
- failure of conservative treatment
210
What do we know about the timing of the surgery for stenosis patient?
* Surgery delay of 3+ months did not worsen prognosis
* Leg P lasting >1 year long may have poorer surgical outcome
So a treatment trial of 3 months is a viable option
CP II - Beck
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