2 - Ortho: Spine Flashcards
What are sources of primary bone pain? What nerves carry this pain?
Sources: Microfracture, osteoarthritis, vascular congestion, infarction
Nerves: intramedullary and periosteal nerve fibers
Edema and inflammation irritates the surrounding tissue and causes more pain
What are the sources of paraspinal muscle and tendon pain?
Sources: Direct injury, overuse, inflammation, ischemia, compartment pressure
Nerves: muscle sensory fibers have chemo and mechano receptors that can respond to anaerobic metabolites, pressure, and stretch.
What are the sources of facet joint pain?
Derangement of subluxation of joint causes articular cartilage degeneration and subchondral fracture
Nerve endings can signal both impending and actual damage to the facets
Explain the mechanism of guarding reflexes in the onset of facet joint arthropathy.
Articular nerves pass through the muscular and cutaneous tissue to reach the joint, mediate protective reflexes
Describe the vascularity of the facet joints
Synovial tissue of the factes is highly vascular and neurogenic. Distention of joint fluid can cause immense pain.
What is the nerve supply to the articular facets?
Dorsal Ramii
What nerve supplies the IV disc, PLL, ventral dura, and posterior annulus fibrosis?
Sinuvertebral Nerve, close proximity to DRG can cause pain sensations
Innervates the PLL the most
(formed by a union of somatic and autonomic roots of the ventral ramus and gray ramus communicans)
what is the most richly innervated spinal ligament?
PLL - sensitive to pressure, distention, chemical irritation (prostaglandins from DJD)
Describe dorsal root ganglion pain.
Sensitive to pressure, chemicals (prostaglandins)
Pain discharge is long even after brief compression of the nerve
What is pain localized to the back frequently attributed to?
Sinuvertebral nerve pain related to DRG compression
What is the cause of disc degeneration with aging?
Proteoglycan in disc holds less water, decreases resilience and turgor
Explain the progression of degenerative disc disease.
Small exursions and abnormal motion can cause pain and spasms, but neuro exams and x-rays are normal early on
Later on - arthropathy increases, disc spaces narrow, osteophytes form, and x-rays come back positive
What is often seen on MRI in degenerative disc disease, unique to this!
Vacuum disc phenomenon - ragged edged dark pocket, dark on T2 image
What are the treatment options for patients with DDD?
Non-surgical: braces, medication, PT, weight loss, pain management
Surgical: Arthrodesis, or Disc Replacement
What tests are usually done if DDD is suspected
MRI is first line (T2) will show loss of fluid in disc space
Meyelogram with contrast if MRI is contraindicated
What is the most common cause of sciatica?
HNP - hydrostatic nature disrupted
What level is the patellar tendon reflex?
L4
What level is the Achilles reflex?
S1
What is the motor strength level of tib anterior?
L4
What is extension of the toes level?
L5
What is the eversion motor level?
S1
What modalities can be used for objective testing of the
First line is Xray followed by more compex modalities
CT = Great boney details!
Myelography = iodine based dye to visualize the flow of the material/displacement by pathology (contrindications are iodine allergy).
Discogram = inject dye into disc to visualize well
EMG - for nerve conduction velocity
What are the indications for surgery with sciatica?
Failure to respond to conservative care
Muscle weakness (reflex changes)
Instability
Intractible pain
What is cauda equina syndrome?
Saddle anesthesia symptoms, can be a result of severe spinal stenosis
Caused by a large central disc herniation around the L3/L4 level that compresses the cauda equina
