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PassPMR - 07 Musculoskeletal Medicine > 1a- Spine & Back > Flashcards

1a- Spine & Back Flashcards

1
Q

Labeling

A
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2
Q

Describe the borders of the neural foramina (intervertebral foramen).

A
  1. ANTERIOR: Vertebral body
  2. POSTERIOR: Facet Joint
  3. SUPERIOR & INFERIOR: Superior and inferior pedicles
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3
Q

Diagram of Scotty dog (lumbar spine x-ray oblique view) 🔑🔑

A
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4
Q

Anatomy & Innervation of intervertebral disc 🔑🔑 EXAM 2020

A

Components

  1. Nucleus pulposus:
    • Water and proteoglycans in a network of Type II collagen
  2. Annulus fibrosus
    • Type I collagen fibers arranged in obliquely
    • Withstands distraction forces, more susceptible to injury with torsional stresses.
  3. Vertebral endplate
    • Cartilaginous covering forming the top and the bottom of the disc

Function

  1. Allows for vertebral body motion
  2. Weight bearing

Innervation

  • Anterolateral part of the annulus fibrosis innervated by ventral rami and gray rami communicans
  • Posterior part of the annulus fibrosis innervated by sinuvertebral nerves (recurrent branches off of the ventral rami).

Cuccurollo 4th Edition Chapter 4 MSK pg283-284

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5
Q

Spine motion & muscle activity. 🔑🔑 Dr. Abdulrazaq

Which part of cervical vertebra does most of the rotational ROM?

Which part of thoracic vertebra does most of the rotational ROM? Flexion & Extension?

Which part of lumbosacral vertebra does most of the rotational ROM? Flexion & Extension?

A

CERVICAL

  • Flexion-Extension: Atlanto-occipital joint (قمة راسك)
  • Rotation: Atlanto-axial joint (Odontoid Process)
  • Lateral Bending: Middle of cervical vertebra

THORACIC

  • Flexion-Extension & Lateral Bending: T11-T12 (Belly Dancer)
  • Axial Rotation T1 to T8 (Hold your arms and rotate)

LUMBOSACRAL

  • Flexion-Extension: Lower Segments L5-S1 (Butt)
  • Lateral Bending L3-L4 Middle
  • Minimal Rotation: To protect the cauda equina

MUSCLES

  • Paraspinal Muscles
    1. Bilateral: Extensors to resist the pull of gravity in sitting and standing
    2. Unilateral
      • Superficial → ipsilateral rotation
      • Deep → contralateral rotation
  • Primary Lateral Flexors
    1. Quadrati lumborum
    2. Oblique abdominal muscles.
  • Primary flexors
    1. Psoas
    2. Assisted by the recti abdominus.

Braddom 6th Edition Chapter 13 Spinal Orthoses pg250 Fig. 13.2

DeLisa 5th Edition Chapter 34 Scoliosis pg887

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6
Q

Spinal Motion Segment: The Three-Joint Complex

A
  1. Vertebral body endplate-disc-endplate joint
  2. Two Zygapophyseal joint (facet joint)
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7
Q

List 3 possible sites for needle insertion when doing epidural steroid injections 🔑🔑

A
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8
Q

A patient received transforaminal injection for L5 radiculopathy. 2 weeks later, he comes back with worsened back and leg pain with decreased movement. Give 3 most likely diagnosis.

A
  1. Nerve damage secondary to intervention (nerve root injury)
  2. Nerve root transection
  3. Growing hematoma
  4. Abscess (epidural)
  5. Meningitis
  6. Anterior cord syndrome
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9
Q

Name 4 complications of discography.

A
  1. Infection
  2. Bleeding
  3. Further injury to the disc
  4. Allergy to the dye
  5. Pain
  6. Nerve/root injury
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10
Q

List 4 Spondylotic changes causing spinal stenosis. 🔑

Classifications of spinal stenosis 🔑🔑 Leak 21

What areas can be entrapped in lumbar spine lateral stenosis? 🔑

A

Spondylotic Changes in MRI

  1. Disc space narrowing
  2. Vertebral body osteophytosis
  3. Facet joint arthropathy
  4. Ligamentum flavum hypertrophy.

Classifications

  1. Centra Stenosis
    • Normal spinal cord is approximately 10 mm in diameter; the spinal canal is 17 mm.
    • Relative stenosis central canal is <12
    • Absolute stenosis central canal is 10 mm
  2. Lateral Stenosis
    • Lateral recess
    • Mid zone
    • Intervertebral foramen

Presentation

💡 Myelopathic changes may be noted with higher spinal cord level involvement if there is significant enough cord compression

  1. Symptoms typically exacerbate with lumbar extension (standing/walking)
  2. Pain in the buttock, thigh, or leg with standing or walking
  3. Improved with lumbar flexion (sitting/bending forward).
  4. Improved with sitting or leaning forward (“shopping cart sign”).
  5. Gradual neck or back discomfort with upper or lower limb involvement

ER - POLICE - MS

LOADING

  • Focus on a flexion- or neutral-biased spinal stabilization program
  • Aquatic therapy

MEDICATION

  • Epidural steroid injection

SURGERY

  • Surgical procedures including decompression and/or stabilization

Cuccurollo 4th Edition Chapter 4 MSK pg297-298

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11
Q

List 4 Causes of spinal canal stenosis 🔑🔑 Leak 21

A

CONGINITAL

  1. Hereditary
  2. Achondroplastic
    • Genetic condition affecting a protein in the body called the fibroblast growth factor receptor. In achondroplasia, this protein begins to function abnormally, slowing down the growth of bone in the cartilage of the growth plate

ACQUIRED

  1. Degenerative (most common)
  2. Spondylosis or Spondylolisthesis
  3. Iatrogenic (post laminectomy or fusion)
  4. Posttraumatic
  5. Metabolic (Paget’s disease)
  6. Mass lesion (e.g., disc herniation, tumor, abscess)

Cuccurollo 4th Edition Chapter 4 MSK pg298

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12
Q

What is the most common level of radiculopathy in the lumbar region?

What lumbar region is most commonly involved in spinal stenosis?

A

RADICULOPATHY

L5, associated with L5/S1 foraminal stenosis.

Ref: Delisa, pg 863.

SPINAL STENOSIS

L3 and L4 levels

Ref: Cuccurullo

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13
Q

What are 3 indications for surgical referral of spinal stenosis?

A

CORD COMPRESSION → SCI

  1. Gait ataxia/upper motor neuron changes = myelopathy
  2. Bowel/bladder /sexual dysfunction

TUMOR/INFECTION

  1. Night pain/weight loss = tumor
  2. Fevers/chills = infection
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14
Q

Compare neurogenic vs vascular claudication 🔑

A

Cuccurollo 4th Edition Chapter 4 MSK pg299

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15
Q

Localized back pain exacerbated by motion (hyperextension), standing, lying prone, and relieved with flexion. Spot diagnosis, radiological findings & management.

A

SPONDYLOLYSIS

  • It is a fracture of the pars interarticularis, which is located at the junction of the pedicle, lamina, and the superior articular process (SAP).
  • Result of repetitive hyperextension and rotational forces.

Presentation

  • Localized back pain exacerbated by motion (hyperextension), standing, lying prone
  • Relieved with flexion
  • Neurologic exam should be normal.

Imaging

  • Oblique x-rays: “broken neck” on the “Scotty dog”
  • Bone scans may be positive at 5 to 7 days and last up to 18 months
  • SPECT increases bone scanning sensitivity
  • High-resolution MRI

ER - POLICE - MS

  • Education: Relative rest
  • Protection: Avoidance of high impact exercises/activities until pain free
  • Physiotherapy: Flexion based and stabilization exercises
  • Gradual transition back to play

Cuccurollo 4th Edition Chapter 4 MSK pg299-300

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16
Q

Define spoldylolisthesis. What is the classification or grading based on? red flag?

What is the meyerding classification of spondylolisthesis?

A

Spoldylolisthesis

  • Translation of a vertebral body with respect to the vertebral body below it
  • It may be an anterior translation (anterolisthesis) or posterior translation (retrolisthesis)
  • Most commonly at L5–S1 and then at L4–L5.

Meyerding Classification (attached)

Presentation

  • Low back pain worsen with lumbar extension and activities (standing and walking)
  • Back pain that can radiate to the buttocks or LEs.
  • Radicular symptoms may occur with marked slippage
  • Palpable step-off noted at the slippage site
  • Central or foraminal stenosis.
  • Severe neurologic deficits such as cauda equina syndrome (rare)
  • Hamstring tightness

Grading of a spondylolisthesis

  • Based on the percentage displacement with respect to the vertebral body below.

Imaging

  • Radiographs (AP, lateral, and oblique views)
    • Dynamic flexion–extension x-rays should be performed when there is suspicion of dynamic instability of the spondylolisthesis
  • MRI is recommended when neurological deficits are noted

NON SURGICAL Slip < 50% + Asymptomatic

  • Education
    1. Precautions to avoid spinal extension
    2. Relative rest, eliminate aggravating activities
    3. Restricted from contact sports
  • Protection & Orthosis
    1. Thoracolumbosacral orthosis (TLSO) bracing
      • Increased pain occurs despite decreased activity
      • Increase in slippage is suspected
  • Physiotherapy
    1. Focus on spinal stabilization exercises

SURGICAL SLIP > 50% + Symptomatic

  1. Unstable spondylolistheses
  2. Radiographic instability
    1. Translation >3.5 mm (cervical) and >5 mm (thoracic or lumbar).
    2. Rotation > 11 degrees (cervical) and 15 degrees (thoracic or lumbar).

Cuccurollo 4th Edition Chapter 4 MSK pg300-302

Cuccurollo 4th Edition Chapter 10 Pediatrics pg751-752

17
Q

Etiologies of Spondylolisthesis 🔑🔑

A
  1. Isthmic (Pars interarticularis fracture L5–S1, most common type)
  2. Dysplastic (congenital malformation of the facet joints)
  3. Degenerative (Facet arthrosis causing subluxation, L4-L5)
  4. Traumatic
  5. Pathological (Cancer, infection, metabolic disorder)
  6. Postsurgical

Cuccurollo 4th Edition Chapter 4 MSK pg301 Table

18
Q

Teach R1-R2 resident about Facet Joints. 🔑🔑 Dr. Jamal & Dr. Abdulrazaq

A

SYNOVIAL JOINT

  1. Superior articulating process
  2. Inferior articulating process
  3. Meniscus
  4. Articular cartilage
  5. Joint capsule

FUNCTION

  1. Limit vertebral motion
  2. Resist shearing and rotational forces
  3. Weight bearing

INNERVATION

Two medial branch nerves from spinal nerve dorsal rami

Cervical: top spinal level and level below (C1 → C1 & C2)

C5–C6 facet is innervated by C5 and C6 medial branches

Lumbar: top spinal level and level above (S5 → S5 & S4)

L4–L5 facet is innervated by the L4 and L3 medial branches

ORENTATION

Atlanto-axial (AA) and atlanto-occipital (AO) joints

  • No true facet joints due to their atypical anatomy

C3–C7 and thoracic facets

  • Frontal (coronal) & transverse plane → Allow motion

Thoracic facets

  • Frontal (coronal) plane → Allow link to rib cage

Lumbar facets

  • Sagittal plane → Limiting lateral rotation

Cuccurollo 4th Edition Chapter 4 MSK pg282-283

19
Q

Face arthrtopathy. Presentation, Diagnosis & Treatment 🔑

A

CLINICAL PRESENTATION

  • Axial pain pattern with a radicular pain pattern presentation
  • Neck or back pain exacerbated with rotation and extension (Kemps test)
  • No neurologic abnormalities

IMAGING

  • No imaging study is specific for facet-mediated pain
  • MRI may show hypertrophy of the capsule and facets.
    • Green arrow points at a normal joint
    • Red arrow points at a degenerated joint.

DIAGNOSIS

  • Double diagnostic medial branch blocks

ER-POLICE-MS

  • Relative rest
  • Lumbar spine stabilization in flexion-biased or neutral postures
  • Proper body mechanics
  • Medications for pain control

INTERVENTION

  • Indicated if diagnostic blocks are positive.
  • Facet joint injections or dorsal rami medial branch radiofrequency (RF) ablation

Cuccurollo 4th Edition Chapter 4 MSK pg308

20
Q

Gradual back, buttock, leg, and groin pain with tenderness over SI joint.

List 4 Deferential Diagnosis, 4 Test for SI Joint & Diagnostic Tool. 🔑🔑

A

SACROILIAC JOINT DYSFUNCTION

Presentation

  • Presents localized low back pain, muscular in origin with negative red flags.
  • Acute or gradual back, buttock, leg, or groin pain with tenderness over the joint
  • Increased discomfort with positional changes
  • Discomfort in quadratus lumborum, erector spinae, and piriformis muscles
  • No neurologic abnormalities are present

https://www.researchgate.net/figure/Pain-distribution-patterns-in-sacroiliac-joint-dysfunction-Type-E-undetermined-type-is_fig1_240116733

Etiology

  1. Hyper/hypomobile joint patterns
  2. Repetitive overloads
  3. Trauma
  4. Capsular tears/injury

Physical Examination

  1. Gillet’s Test (Restriction in ROM)
  2. Distraction Test
  3. Gaenslen Test
  4. Hip Thrust
  5. FABER/Patrik Test (Posterior pain)
  6. Iliac Compression Test
  7. Sacral Thrust/Compression Test

Imaging

  • Imaging is unreliable in diagnosing SI joint dysfunction.
  • MRI: Sacroiliitis, early bone marrow edema

Diagnosis

  • SI joint blocks under fluoroscopic guidance have a higher diagnostic value
  • Serology workup can be indicated for underlying arthropathies

Diseases Affecting SI Joint

  1. Inflammatory - Seronegatives Ankylosing spondylosis, Psoriatic arthritis, Reiters syndrome, IBD: Crohn’s disease and ulcerative colitis
  2. Hormonal – pregnancy
  3. Degenerative - OA
  4. Mechanical - Leg length discrepancy, over-pronation, twisting of the pelvis, muscle imbalance
  5. Hypermobelity - Marfan, Ehlos Danlos

SI Joint Dysfunction

  1. Hyper/hypomobile joint patterns: Marfan, Ehlos Danlos
  2. Repetitive overloads
  3. Trauma
  4. Capsular tears/injury

ER-POLICE-MS

  • Education: Relative rest
  • Protection & Orthosis: SI joint belt.
  • Loading: Manual therapy
  • Medications: NSAIDs
  • Intervention: SI joint injections

Cuccurollo 4th Edition Chapter 4 MSK pg310-311 + Flash Cards

21
Q

28yo lifter complained of back pain associated with spasms and guarding for 2 days.

List 4 Causes of mechanical back pain 🔑

Examination, Imaging, Treatment (MSK Clinic)

A

Presentation

  • Muscular strain or ligamentous sprain due to overload injuries.
  • Muscle aches with associated spasm and guarding in the region of injury.
  • Delayed onset muscle soreness can occur within 24 to 48 hours typically after an eccentric overload injury.
  • Normal neurologic exam

Etiology

  1. Overuse syndromes
  2. Excessive eccentric contraction
  3. Acceleration–deceleration injuries
  4. Acute trauma

Imaging

  • Decreased lordotic curvature due to muscle spasm

ER-POLICE-MS

  • Education: Relative rest
  • Loading
    • Increase mobility & flexibility
    • Range of motion (ROM) strengthening
    • Spine stabilization exercises
    • Manual medicine
  • Medication: Analgesics PRN.

Cuccurollo 4th Edition Chapter 4 MSK pg311

22
Q

Labour worker with history of fall now complain of back pain

Exacerbated with valsalva maneuvers, turning in bed, coughing, flexion.

Diagnosis, Is he stable or not? conservative or surgical treatment? 🔑🔑 Dr. Jamal

A

VERTEBRAL BODY COMPRESSION FRACTURE

  • Typically associated with osteoporosis
  • Most commonly seen at the thoracolumbar junction.

Etiology

  • Trauma, Osteoporosis/osteopenia, Osteomalacia, Medication related, Neoplasm

Investigation

  • Bone density (BMD) or oncology evaluation (pathologic fracture)

ER-POLICE-MS

  • Education
    • Bone density (BMD) or oncology evaluation (pathologic fracture)
    • Short-term bedrest followed by activity restriction
  • Protection & Orthosis
    • Indicated for fractures causing <25% decrease of vertebral height.
    • Elastic Binder
      • Acts as a reminder to limit motion
      • Increases intra-abdominal pressure
    • Custom-molded TLSO/Jewett brace
      • Greater immobilization
      • Places patient in slight hyperflexion
      • Caution in the osteoporotic patient
  • Loading: Hyperextension focus
  • ICE & Modalities
  • Medications for pain control
  • Surgery
    • Vertebral augmentation (vertebroplasty or kyphoplasty)
    • Indications
      1. <50% decrease of vertebral height
      2. Instability
      3. Late kyphotic deformity leading to neurologic compromise.

Cuccurollo 4th Edition Chapter 4 MSK pg305-307

23
Q

30yo man involved in RTA, complain of weakness in lower limbs and incontinence.

Diagnosis, conservative or surgical treatment?

A

VERTEBRAL BODY BURST FRACTURES

  • Fracture of anterior and middle columns of the spine
  • Result from significant trauma, typically from a fall from a height.

Stable → Bracing for 4 to 6 months

  • Neurologically intact.
  • Posterior column remains intact
  • <50% collapse of anterior vertebral body height
  • Xray to follow up kyphosis

Unstable → Surgical decompression and fusion

  • Neurologic deficits present
  • Posterior element injury
  • >50% loss of anterior vertebral body height
  • Central canal compromise >30%

Cuccurollo 4th Edition Chapter 4 MSK pg307-308

24
Q

List 2 Reasons for atlantoaxial instability in Downs syndrome.

A
  1. Congenital absence or laxity of transverse (atlas) ligament
  2. Malformation of the odontoid bone
  3. C1 hypoplasia causing spinal stenosis

Ref: emedicine – AAI (atlantoaxial instability).

25
Q

List 6 Causes of myelopathy.

A
  1. Tumors (mass)
  2. Arteriovenous (AV) malformations (artery)
  3. Multiple sclerosis (infiltration)
  4. Syphilis (infection)
  5. Syringomyelia (mass)
  6. Amyotrophic lateral sclerosis (infiltration)
  7. RA (C1–C2 subluxation) (ligament)
  8. Spondylosis (degenerative)

Cuccurollo 4th Edition Chapter 4 MSK pg295

26
Q

What is normal atlantoaxial distance? Name the ligament that provides stability.

List 2 conditions which predispose to atlantoaxial instability 🔑🔑

A

Normal atlantoaxial distance:

Distance between odontoid process and the posterior border of the anterior arch of the atlas) of greater than 3 mm in adults and of greater than 5 mm in children as measured on plain radiography

Ligament

  1. Transverse ligament (primary stabilizer)
  2. Alar & Apical ligaments (secondary stabilizers)

Predisposing factors for atlantoaxial instability:

  1. Rheumatoid arthritis
  2. Down syndrome
  3. Ankylosing spondylitits
  4. Achondroplasia
27
Q

Back pain with thoracic kyphosis remains fixed and does not correct with hyperextension.

Diagnosis

List 4 X-Ray Findings 🔑🔑

Management.

A

SCHEUERMANN’S DISEASE (JUVENILE KYPHOSIS)

X-Ray Findings

  1. Anterior wedging of at least three adjacent vertebrae with >5 degrees
  2. Fixed thoracolumbar kyphosis
  3. Intervertebral disc herniation
  4. Irregular endplate
  5. Schmorl’s nodes: herniation of disc material through the vertebral endplate
  6. Disk-space narrowing

Presentation

  • Progressive, nonpainful thoracic kyphosis
  • Thoracic kyphosis remains fixed and does not correct with hyperextension
  • Back pain may occur in young athletes due to localized stress injury to the vertebral growth plates.

Conservative <50 degrees

  • PT, anti-inflammatories, behavior modification

Bracing for 50 degrees to 75 degrees

  • Thoracic–lumbar–sacral orthosis (TLSO)
  • PT, anti-inflammatories, behavior modification

Surgery recommended in cases with

  1. <65 degrees in the skeletally mature
  2. 75-degree curvature
  3. Refractory pain
  4. Neurologic deficit due to severity of kyphosis

Cuccurollo 4th Edition Chapter 4 MSK pg305

Cuccurollo 4th Edition Chapter 10 Pediatrics pg751

28
Q

Common Disc Herniation? Radiculopathy? 🔑🔑 Leak 21

A

Majority of spinal disc herniations occur in the lumbar spine

95% at L4–L5 or L5–S1 → Radiculopathy L5 & S1

https://en.wikipedia.org/wiki/Spinal_disc_herniation

PassPMR - 07 Musculoskeletal Medicine (8 decks)

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