Dejerine’s Sign

Dejerine’s Sign

Clinical Pearl

Patients with radicular symptoms and pronounced Dejerine’s sign, especially if it is in the lumbar spine, should be told to bend the knees and lean into a wall during a cough or sneeze. This maneuver reduces intradiscal pressure and minimizes the effect of the cough or sneeze on the nerve root. A more worrisome situation is the sudden, unexpected absence of Dejerine’s sign when all other clinical findings indicate an active nerve root compression. The loss of the sign indicates fragmentation of the disc with momentary decompression of the nerve.

Brachial Plexus Tension Test

Brachial Plexus Tension Test

Clinical Pearl

Although the brachial plexus tension test involves shoulder joint movement, it also provides maximum stretch on the brachial plexus, which affects the lower branches of the cervical spine (C5) the most. If this test is positive, the early stages of a C5 nerve root disorder may be present along with the subtle signs of a positive doorbell sign (pain that occurs at the superior scapulovertebral border and radiates with the use of deep palpation of the C5 segment) and pain in the deltoid area. The deltoid pain is often misconstrued as an articular problem of the shoulder.

Definition of Pain

Definition of Pain

The International Association Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Pain is a prominent symptom in many acute injuries and illnesses, and often subsides as the medical condition resolves. Since such acute pain is usually short lived, it is not a problem that is considered in an impairment rating system. However, chronic pain is a problem that potentially could be the cause for an impairment rating. The definition of chronic pain is imprecise but, in a general way, it refers to pain that persists over time. For the purposes of the Guides, chronic pain is defined as pain that persists beyond the expected healing time of the medical disorder thought to have initiated the pain. For many sections in the Guides, chronic pain will be pain that persists beyond 3 months, as most common conditions affecting the musculoskeletal and other organ and systems will substantially heal in this time frame. The nervous system is a notable exception. Although any time point is arbitrary, 3 months should encompass the expected healing time in most situations where there is tissue injury but will allow for situations in which there is no expected healing time. 

Workers' Compensation

Workers’ Compensation

There is increased use of the Guides to translate objective clinical findings into a percentage of the whole person. Typically this number is used to measure the residual deficit, a loss--a number that is then converted to a monetary award to the injured party. The scheme is most commonly used in various workers’ compensation systems in the United States and abroad.

In the United States, 44 states, 2 commonwealths, and federal employee compensation systems (in about 90+% of US jurisdictions) either mandate or recommend using the Guides to measure impairment in workers’ compensation cases, the Guides is often used to assess damages in personal injury claims under federal statutes and state common law.

Soft Tissue Injuries

Soft Tissue Injuries

Injuries to the soft tissues of the body are probably the most frequent cause of musculoskeletal dysfunction. With the recent development and implementation of MRI, it is now possible to evaluate noninvasively all the soft tissue structures in the body (eg, muscles, tendons, ligaments, and cartilage) that may be responsible for a patient’s symptoms. Ultrasonography is also used to assess soft tissue disorders of the musculoskeletal system. The major advantage of US is its availability, safety, and lower cost compared with MRI. It is waves; thus osseous structures or soft tissues shielded by osseous tissue cannot be evaluated. Compared with the other imaging modalities the efficacy of US is heavily dependent on the operator of the equipment, but this should not preclude its use in appropriate clinical situations. Considering its cost and availability, the role of US may grow as staff in more centers become proficient in its application. This is already true in many European countrieswhere US is heavily used in the evaluation of musculoskeletal disorders. The following sections present the role of radiologic imaging in the assessment of patients with musculoskeletal injuries. 

The Cervical Spine

The Cervical Spine

Axioms of Cervical Spine Assessment

1.      Cervical spine syndromes are extremely common and are probably the fourth most common cause of pain.

2.      At any given time, 9% of men and 12% of women have neck pain with or without arm and hand pain, and 35% of the population can remember having had neck pain at some time.

3.      The cervical spine is the origin of a large proportion of shoulder, elbow, hand, and wrist disorders.

4.      Most people who develop pain in the neck do not seek medical attention because they regard such pain as a part of life, so they simply wait for it to disappear.

Disability and Handicap

Disability and Handicap

Disability is a present when a tissue, organ, or system cannot function adequately. A handicap exists when disability interferes with a patient’s daily activities or social/occupational performance. A marked disability does not necessarily cause a handicap. Conversely, minor disability may produce a major handicap. Both conditions require separate assessment. Patients’ perception of their problems will be molded by their adaptation to the depreciated tissue as well as their aspirations for recovery. 

Assessing Disability

An aid in assessing the more important aspects of disability is the PILS mnemonic, which considers four issues:

1.      P Preventable causes of disability (e.g., falls, direct trauma)

2.      I Independence (e.g., self-care)

3.      L Lifestyle (roles, goals)

4.      S Social factors (e.g., family, friends, shelter)

Functional Assessment

A complete functional assessment includes evaluation of the following:

1.      Self-care: ability to wash, bath, attend to toilet needs, dress, cook, and feed oneself

2.      Mobility: ability to stand, transfer, walk, negotiate stairs, drive, and use public transportation

3.      Lifestyle: nature of occupation, work capacity, and Social Security benefits

Clinical Pearl

Clinical Pearl

A straight-leg-raising test this is positive under 30 degrees reveals a large disc protrusion. The nerve root is stretched long before it would normally be. The straight-leg-raising test is most useful for identifying L5-S1 disc lesions because the pressures on the nerve root are highest at this level. During straight leg raising, L4-L5 is not as apt to give as much pain as L5-S1 because the pressure between the disc and the nerve root at L4-L5 is half that at L5-S1. Therefore the L5-S1 disc lesion gives more pain in the lower back and leg than does the L4-L5 disc lesion. No movement on the nerve root occurs until straight leg raising reaches 30 degrees. No movement on L4 occurs during a straight leg raising test. From this, the presence of Turyn’s sign indicates a large disc protrusion at the level of the L5-S1 nerve root.