18: Basic Exam for spine Flashcards
History of cancer and/or Unexplained weight loss -
– r/o malignancy
Loss of bowel or bladder control – r/o
r/o myelopathy or stenosis
Significant weakness in spine r/o
– r/o myelopathy or radiculopathy
Saddle anesthesia – r/o
myelopathy or cauda equina syndrome
Chronic corticosteroid use – r/o
compression fracture
Pt that has Immunosuppression and or fever – r/o
infection
IV drug use and back pain – r/o
infection
Pt with back pain and Prior spine surgery – r/o
hardware failure, adjacent segment disease, recurrent disc
herniation
A patient has back Weakness and/or numbness –
we should be suspicious for
nerve involvement
Pt has Morning stiffness, improves with activity but not with rest (<40 yo) – suspicious for
spondyloarthropathy
fracture of the pars interarticularis
Spondylolysis
anterior displacement of one vertebrae on another
Spondylolisthesis
a. Hyoid bone –
b. Thyroid cartilage –
c. First cricoid ring –
d. Most prominent spinous process –
C3
C4-5
C6
C7
Top of iliac crest located at
L4-5
Posterior superior iliac spine located at
S2
Expected ROM of Cervicle spine
- Rotation:
- Flexion:
- Extension:
- Sidebending:
Cervical spine
- Rotation – ~70°
- Flexion – ~45° (chin to chest)
- Extension – ~55°
- Sidebending – ~40°
Lumbar spine
- Flexion –
- Extension –
- Lateral bending
- Rotation
Lumbar spine
- Flexion – ~75°
- Extension – ~30°
- Lateral bending – ~35°
- Rotation
passive rapid flexion of middle finger distal phalynx. Positive test is flexion of thumb, index finger
Hoffman – signs of Upper Motor Neuron Lesion
stroking sole of foot resulting in great toe extension and toe
spreading
Babinski– signs of Upper Motor Neuron Lesion
Straight leg raise (SLR) – lying supine, leg is raised with knee extended. Positive test is
reproduction of radicular symptoms with hip flexed between 30-70°
Femoral stretch test – lying prone, knee is flexed to 90° and thigh elevated. Positive test is
reproduction of anterior thigh radicular symptoms
Spurling – reproduction of ipsilateral radicular symptoms with cervical spine extension, rotation, lateral sidebending This test suggests
cervical nerve root involvement
Lhermitte – electrical shock sensation in limbs with cervical flexion suggests
cervical cord involvement
Pt comes in with axial low back pain after acute injury, such as lifting or twisting
Lumbar strain
Causes of lumbar strain
muscle disruption from excessive stretch or tension
During exam, pt experiences localized muscle tenderness, reduced ROM in their spine
lumbar strain
What imaging would we get for suspected lumbar strain?
usually none.
Tx for Lumbar Strain
Relative rest, NSAIDs, muscle relaxant, physical
therapy
Pt complains axial low back pain, gradual onset (cervical: worse with cervical extension;
lumbar: worse standing/walking, better sitting/lying)
Osteoarthritis
Etiology of osteoarthritis
gradual degenerative changes/osteoarthritis to zygoapophyseal (facet)
joints; more common age > 55
Expected Exam findings in patient with osteoarthritis
worse with:
better with:
nonspecific, pain provoked with active extension, relieved with flexion
Treatment for OA–
NSAIDs, mild analgesics. Physical therapy (flexion bias), possibly facet joint injections
What imaging would we want to order for expected OA?
Imaging: none or plain lumbar x-rays.
Patient experiences pain and possible numbness/weakness in limb > axial spine
Lumbar: worse sitting/flexion, better standing/extension
Radiculopathy
most common cause of radiculopathy
disc herniation
Expected exam findings of patient with radiculopathy?
SLR or Spurling positive, neurologic deficits (myotomal weakness, decreased reflex, dermatomal reduced sensation)
Imaging ordered for suspected radiculopathy:
MRI, possible EMG.
Tx for patient with radiculopathy
Relative rest, physical therapy, surgical
discectomy if progressive/severe weakness or unresponsive to conservative care. For
pain, NSAIDs, oral or epidural corticosteroids, limited opioids, neuromodulators
Pt comes in with slowly progressive back and unilateral or bilateral leg pain. It is worse when standing, and better when sitting. Positive for shopping cart sign (bc flexes spinal canal)
Lumbar stenosis
You suspect your patient to have lumbar stenosis, what are the key DDx?
Differentiate from vascular claudication (must sit
or bend to relieve symptoms)
Causes of Lumbar Stenosis
narrowing of the spinal canal (due to disc herniation/ protrusion, ligamentum flavum thickening, osseous thickening of bone/facet joint, spondylolisthesis)
Imaging ordered for suspected Lumbar Stenosis
Imaging: MRI, possibly CT or EMG.
Treatment for Lumbar Stenosis
NSAIDs, neuromodulators, physical therapy (flexion bias), use of walker, epidural steroids, surgery for lumbar decompression
Patient comes in with back pain, numbness, weakness in arms and/or legs; balance and gait difficulties;
bowel/bladder dysfunction
cervical myelopathy
Etiology for suspected cervical myelopathy
cervical canal stenosis with spinal cord compression
On exam, patient has arm and/or leg weakness, upper motor neuron signs– hyperreflexia, Hoffman/Babinski, ataxia, and increased tone
Cervical myelopathy
Treatment options for Cervical Myelopathy
Surgical decompression. No role for nonoperative
treatment
What imaging would you order for suspected cervical myelopathy?
MRI
Old patient comes in with sudden thoracic (or lumbar) pain with no history of trauma. On exam they are tender over spinous processes, paraspinals. Worse: lumbar flexion. Better: lumbar extension.
Normal neuro exam (unless nerve root affected)
Compression fracture
Causes of Compression fracture in spine
ii. Etiology – majority related to osteoporosis, older patients; anterior vertebral body
wedge fracture. T10, T11, T12, L1 most commonly. In younger patients w/o clear
etiology, consider malignancy, multiple myeloma. 1/3 are asymptomatic
Patient comes in with suspected comression fracture of spine. What imaging do you order?
plain x-rays, possibly MRI or CT; DEXA scan to eval for
osteoporosis.
If malignancy considered: CBC, SPEP, alkaline phosphatase, sed rate (malignancy for our younger pts)
Tx options for
NSAIDs, acetaminophen, calcitonin, mild opioids. Consider bracing for 6 weeks.
Physical therapy. Symptoms usually improve in 3 months.
Vertebroplasty/kyphoplasty a consideration, evidence of efficacy limited
Pt comes in with onset of low back pain < age 40, insidious, better with exercise, pain at
night and on waking, not improved with rest
Ankylosing spondylitis
Suspected etiology of Ankylosing spondylitis
inflammatory spondyloarthropathy, usually sacroiliitis initially. Can be associated with uveitis, inflammatory bowel disease, psoriasis among other features
On exam, patient i has reduced
Reduced lumbar ROM, often tender to palpation over sacroiliac joints with
positive joint provocative tests (FABER, Gaenslen).
You suspect a patient of having ankylosing spondylitis. What imaging would you order?
Early?
Late?
Labs?
plain x-rays – earliest finding sacroiliitis.
Later syndesmophytes can progress to “bamboo spine”. Labs: HLAB27, C-reactive protein, sed rate.
Tx options for patient with ankylosing spondylitis?
NSAIDs – typically marked relief. Consider anti-TNF agents.
Physical therapy, emphasis on spine extension
Pt comes in and complains of leg pain, numbness, weakness; saddle anesthesia; bowel/bladder
dysfunction (urinary retention most common; urinary or stool incontinence). Dx?
Cauda equina syndrome
Etiology of patient with cauda equina syndrome
large herniated disc compressing cauda equina most common (also epidural tumor, abscess, or hematoma)
What exam findings would you expect to see in someone with cauda equina syndrome?
reduced or absent reflexes, weakness, decreased rectal tone
Tx for cauda equina syndrome?
Surgical emergency
