1a. Approach to Thoracolumbar Complaint

Question 1

Scoliosis most commonly occurs in _____.

Answer 1

Adolescent girls (adolescent idiopathic scoliosis = > 10 degrees angle, >/= 10 years of age)

Question 2

Compensatory scoliosis occurs with _____.

Answer 2

Torticollis, thoracoplasty, congenital dislocation of hip, shortened lower limb

Question 3

Structural scoliosis occurs in ____ and _____.

Answer 3

Congenital deformities and paralysis of the back or abdominal muscles

Question 4

Describe minor functional scoliosis.

Answer 4

Single lateral curve with convexity to the right

Question 5

“De novo” scoliosis is a result of ___.

Answer 5

Long-term effects on the spine

Question 6

Curvature of the spine in the colony plane

Answer 6

Scoliosis

Question 7

Curves with ___ are WNL of spinal asymmetry and have no long-term clinical significance.

Answer 7

Cobb angle <10 degrees

Question 8

Adult spinal deformity

Answer 8

Scoliosis, kyphosis, lordosis, spondylolisthesis

Question 9

What do adult spinal deformities lead to?

Answer 9

Imbalance of structural support of spinal column

Question 10

Prevalence of AIS with Cobb angle > 10 degrees

Answer 10

3% (with 10% requiring treatment); risk of curve progression higher in female

Question 11

Screening scoliosis

Answer 11

(1) Differences in the height of shoulders or scapulae, (2) asymmetry of the waistline, (3) asymmetry in distance that arms hang from trunk, (4) head shift to one side and not centered over sacrum = trunk shift, (5) in patients w/o trunk shift, plumb line drop from SP of 6th C-vertebrae should pass through gluteal cleft

Question 12

Describe test for scoliosis.

Answer 12

Forward bending test: patient bends forward w/ knees extended then side bends left and then right. Physician observes (posteriorly) for accentuation or improvement of spinal curve. Interpretation: Functional curves improve/resolve with sidebending, whereas structural cures do not.

Question 13

What instrument is used to measure spinal curvature?

Answer 13

Scoliometer

Question 14

Treatment for scoliosis is dependent on ___.

Answer 14

Cobb angle, deformity, and risk of progression

Question 15

Scoliosis bracing treatments

Answer 15

Underarm brace or under-chin extension

Question 16

Underarm brace/Boston brace

Answer 16

Thoracic-lumbar-sacral orthosis (TLSO)

Question 17

Under-chin extension/Milwaukee brace

Answer 17

Cervical-thoracic-lumbar-sacral orthosis (CTLSO)

Question 18

When is surgery indicated for scoliosis? What types of surgery?

Answer 18

When the angle > 50 degrees (posterior spinal fusion or anterior spinal fusion; w/ bone grafting; combinations; growth modulation techniques)

Question 19

Duration for acute lower back pain (LBP)

Answer 19

< 6 weeks

Question 20

Duration for subacute lower back pain (LBP)

Answer 20

> 6 weeks

Question 21

Cauda equine syndrome

Answer 21

Surgical emergency for LBP

Question 22

Red flag findings for cauda equina syndrome

Answer 22

• progressive motor or sensory deficits - saddle anesthesia - bilateral sciatica or leg weakness - difficulty urinating (retention) - fecal incontinence - additional indicators of nerve root problems: unilateral leg pain > LBP, pain radiation to foot/toes, numbness/paresthesia within same distribution, SLR inducing leg pain, localized neurological findings (limit to 1 nerve root)

Question 23

Red flag findings that may indicate specific spinal pathology

Answer 23

• onset at age < 20 yo - unrelenting pain at night, unrelated to time or activity (non mechanical), thoracic - widespread neurological symptoms - unexplained weight loss - feeling unwell, fever, chills - significant trauma - penetrating wound near spine - structural spinal deformity - HX osteoporosis, CA; strong suspicion of CA currently; recent infection including UTI; hx immunosuppression

Question 24

Other indicative factors regarding spinal pathology

Answer 24

• HX IVDA/substance abuse - HX steroid use - failure to improve after 4-6 weeks conservative therapy - compression factor dx

Question 25

Diagnosis of compression factor: age/condition, sensitivity, specificity

Answer 25

• >50 yo, sensitivity 84%, specificity 61% - >70 yo, sensitivity 22%, specificity 96% - trauma: sensitivity 30%, specificity 85% - corticosteroid use: sensitivity 6%, specificity 99.5%

Question 26

Diagnosis of herniated disk: sensitivity and specificity

Answer 26

Sensitivity 95%, Specificity 8%

Question 27

Diagnosis of spinal stenosis: sensitivity and specificity

Answer 27

• pseudoclaudication sensitivity 60% - >50yo, sensitivity 90%, specificity 70%

Question 28

Diagnosis of ankylosis spondylitis: age/condition, sensitivity, specificity

Answer 28

• <40 yo, sensitivity 100%, specificity 7% - pain unrelieved supine, sensitivity 80%, specificity 49% - morning back stiffness, sensitivity 64%, specificity 59% - pain duration >3 mo, sensitivity 71%, specificity 54% - 4 of 5 positive responses, sensitivity 23%, specificity 82%

Question 29

Pain or discomfort associated with sciatic nerve

Answer 29

Sciatica

Question 30

Describe characteristic pain associated with sciatica.

Answer 30

Sharp burning pain that radiates from lower back/hip following path of sciatic nerve to foot

Question 31

Neurological involvement is suggested with ___ or ___.

Answer 31

Sciatica or pseudoclaudication (pain radiating distally below knee vs. pain radiating to posterior thigh)

Question 32

Important diagnoses for LBP

Answer 32

Acute/chronic functional LBP, muscular strain, OA, RA, herniated disk, spinal stenosis, sciatica, sacroiliac is, cauda equina, piriformis syndrome, fibromyalgia, duodenal ulcer, pyelonephritis, pancreatitis, prostatitis, hip OA