091214 anatomy of spine Flashcards
cervical and lumbar vertebrae are more prone to injury because
increased motion of cervical area
increased weight bearing of lumbar area
if you have problem going on w/ thoracic area, think..
maybe tumor instead of just musculoskeletal, b/c thoracic area has less movement and greater stability with the rib cage
exam of musculoskeletal spine
observe
palpate
ROM exam
neuromuscular exam (muscle testing, sensory testing, reflex testing)
special tests (spurling’s, Llamette’s)
examine related areas (shoulder for cervical spine, hip for lumbar spine)
myotome
muscle fibers innervated by motor axons within each segmental nerve root
dermatome
area of skin innervated by the sensory axons within each segmental nerve root
shingles
acute neuralgia confined to dermatome distribution of specific spinal or cranial sensory nerve root
palpation of hyoid bone-what dermatome level is it at?
C3
causes of muscle weakness
muscle strain pain/reflex inhibition peripheral nerve injury nerve root lesion (myotome) upper motor neuron lesion (stroke, MS) tendon pathology avulsion pshychologic (no effort)
Lhermitte’s sign
passive anterior cervical flexion elicits electric-like sesation down the spine or extremities
implies cervical spinal cord pathology
Spurling’s neck compression test
with cervical spine extension, rotation, and lateral flexion, you get reproduction of radicular symptoms
implies cervical nerve root pathology
Hoffmann’s sign
flick the pt’s middle finger distal phalanx
positive test would show that pt’s ipsilateral thumb and index finger would flex-adduct
implies upper motor neuron process affecing cervical spine or brain, but not all who test positive for Hoffmann’s do have UMN process (could be an anxious pt, etc)
straight leg raise test (or Lasegue sign)
patient lies supine while leg is raised passively with the knee extended. examiner stops raising the leg when the pt feels pain
positive test would be leg pain being elicited at 30-70 degrees
implies lumbar nerve root pathology (L5 or S1)
femoral nerve stretch test
pt placed in prone position while the knee is flexed
positive test is when it reproduces pt’s pain in anterior thigh
implies upper lumbar nerve root pathology
what should you think of with regards to upper motor neuron injury? (what types of causes?)
spinal cord injury
brain injury or stroke
myelopathy
CNS lesion
when you hear lower motor neuron injury, what cuases should you think of?
peripheral nerve entrapment
radiculopathy
red flags for serious conditions of spine
malignancy (hx of cancer, unexplained weight loss, age >50)
spinal fracture (major trauma, minor trauma or strenuous lifting in older or osteoporotic individual, prolonged corticosteroid use, osteoporosis, advanced age >70yo)
infection (constitutional symptoms, recent bacterial infection like UTI or skin or lungs, immunosuppression, IV drug user)
lumbar strain hx is usually
axial low back pain after acute injury or long time working in yard, etc.
stiffness and limited ROM, localized tenderness in muscle
neuro exam is normal
treatment for lumbar strain
relative rest
anti-inflam
usually PT is not necessary but if ongoing for more than 1 month, should do PT
radiculopathy
most commonly from posterolateral herniation
means a pinched nerve root in the spine
in cervical spine: C6, C7 radiculopathies are most common
in lumbar spine: L5, S1 radiculopathies most common
dermatomes
see dermatome map to review distribution
pathophysiology of nerve root compression
two things:
mechanical compression– induces neural ischemia and increased intraneural pres, edema or nerve root and dorsal root ganglia. dura is sensitive
biochemical irritation–nucleus pulposis contains cytokines, leukotrienes, cox-2, interleukin-1, TNFalpha. biochemical irritation can cause apoptosis of DRG cells
disc herniation hx
often picking up something not necessarily even heavy, get pain in the limbs more so than axial
can be acute or also can be insidious
what makes lumbar disc herniation worse?
sitting
bending
cough, sneeze
what makes cervical disc herniation worse?
movement, especially towards affected side (like the Spurling’s test)
disc herniation exam findings
myotomal weakness
dermatomal pain, numbness, tingling
decreased or absent reflex of affected nerve
Spurling or straight leg raise positive
treatments for disc herniation
activity modification pain medication (NSAIDs (for the biochemical effects), neuromodulators like gabapentin and pregabalin, prednisone, limited opioids)
PT
epidural steroid injection for pain control
disc herniation indications for discectomy
progressive weakness
refractory symptoms
bowel or bladder dysfxn
myelopathy
70-80% improve without surgery
ankylosing spondylitis
SI joint-sclerotic (inflam eats away)
late-you get thin calcifications in anterior ligament of the spine–get fused entire lumbar spine–limited ROM, bamboo spine. can get SI joint completely fused.
early stage of ankylosing spondylitis
widening of SI joint, adjacent sclerosis
posterior longitudinal ligament sclerosis
late stage of ankylosing spondylitis
fusion of both SI joints
symmetric syndesmophytes bridging all vertebral bodies–get bamboo spine
ossification of anterior, posterior, and interspinous longitudinal ligaments
ankylosing spondylitis involves inflam of?
SI joints
axial skeletal joints
enthesitis
chondritis
osteitis
systemic effects of ankylosing spondylitis
lung fibrosis
iritis
CV
what lab marker is positive for ankylosing spondylitis
90% HLA-B27 positive (but if positive, doesn’t mean you have it)
ESR, sed rate
spondylolisthesis can be very bad b/c
this bilateral defect causes slippage of the vertebrae, causing neuro problems
arthropathy
disease of a joint
60 yo degenerative changes of spine
degenerative disc
facet arthropathy
facet joint arthropathy hx
gradual onset
low back pain
lumbar: worse w/ standing, walking and extension. better with sitting and lying
cervical: worse with cervical extension
etiology of facet joint arthropathy
gradual degenerative changes or osteoarthritis to the facet joints
exam findings of facet joint arthropathy
non specific
pain worse w/ active extension, relieved by flexion
lumbar stenosis hx
slowly progressive
pain in back and one or both legs
worse with standing and walking
better with lumbar flexion and sitting (biomechanically, when we extend our spine, it actually narrows the spinal canal)
diff btwn lumbar stenosis and peripheral vascular disease symptoms
person with PVD can just stop and stand (they don’t need to bend or change spinal condition, as long as there’s enough oxygen to muscles their pain will go away)
spinal stenosis-need to lean over something
lumbar stenosis exam findings
check pulse - if pulse is good, they don’t have peripheral vascular disease (can rule this out of differential)
no focal findings
neuro exam is normal
etiology of lumbar stenosis
disc disease
osseous thickening of bone, facet joints, spondylolisthesis
thickening of ligamentum flavum
all of the above can contribute to the disease
lumbar stenosis
PT gait aid-facilitate flexion NSAIDs, neuromodulators epidural steroids surgical treatment if reallyk intolerable
in older pts, compression fracture in spine usually occurs where
in L1-L4
compression fractures of vertebrae tend to occur where in the veretebrae?
anterior wedge
compression fractures-majority of them occur in whom?
people with osteoporosis
hx of compression fracture
usually sudden onset of thoracic or lumbar pain
can be related to trauma or often, little or no trauma
worse with flexion and movement
better with rest
usually no leg pain unless there’s retropulsion and nerve is affected
exam findings for compression fracture
local tenderness
painful lumbar ROM (especially flexion)
imaging for compression frac
get plain XR
consider MRI or CT if you think it’s pathologic fracture
treatment for compression frac
acetaminophen, calcitonin, mild opioids consider bracing (if lot of pain)
hx of cauda equina syndrome
back pain
leg pain, numbness, weakness
saddle anesthesia
bowel and bladder dysfunction
etiology of cauda equina syndrome
large disc herniation compressing cauda equina most common (also could be epidural tumor, abscess, or hematoma)
exam findings for cauda equina syndrome
reduced or absent reflexes, weakness, decreased rectal tone
treatment for cauda equina syndrome
emergency surgery
cervical myelopathy can be from acute or chronic condition-true or false?
true
key difference btwn cervical and lumbar stenosis?
cervical-can affect upper motor neurons
lumbar-past L1 and L2, is just lower motor neuron problem
hx of cervical myelopathy
usually over 50 yrs old
varied presentation
often loss of fine motor skills and hand clumsiness
gait disturbance
may or may not have bowel or bladder effects
motor weakness
lower extremity numbeness, weakness, pain
exam findings of cervical myelopathy
upper and lower extremities with predominantly upper motor neuron finds and weakness below level of cord involvement
positive Babinski, ankle clonus, Hoffmann’s sign
Llhermitte sign
Romberg sign (close eyes and stand)-may be positive due to loss of proprioception
wide based gait b/c of the risk of fall
treatment for cervical myelopathy
usually surgical (cervical decompression-laminectomy)
