2 - Ortho: Spine

Question 1

What are sources of primary bone pain? What nerves carry this pain?

Answer 1

Sources: Microfracture, osteoarthritis, vascular congestion, infarction

Nerves: intramedullary and periosteal nerve fibers

Edema and inflammation irritates the surrounding tissue and causes more pain

Question 2

What are the sources of paraspinal muscle and tendon pain?

Answer 2

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.

Question 3

What are the sources of facet joint pain?

Answer 3

Derangement of subluxation of joint causes articular cartilage degeneration and subchondral fracture

Nerve endings can signal both impending and actual damage to the facets

Question 4

Explain the mechanism of guarding reflexes in the onset of facet joint arthropathy.

Answer 4

Articular nerves pass through the muscular and cutaneous tissue to reach the joint, mediate protective reflexes

Question 5

Describe the vascularity of the facet joints

Answer 5

Synovial tissue of the factes is highly vascular and neurogenic. Distention of joint fluid can cause immense pain.

Question 6

What is the nerve supply to the articular facets?

Answer 6

Dorsal Ramii

Question 7

What nerve supplies the IV disc, PLL, ventral dura, and posterior annulus fibrosis?

Answer 7

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)

Question 8

what is the most richly innervated spinal ligament?

Answer 8

PLL - sensitive to pressure, distention, chemical irritation (prostaglandins from DJD)

Question 9

Describe dorsal root ganglion pain.

Answer 9

Sensitive to pressure, chemicals (prostaglandins)

Pain discharge is long even after brief compression of the nerve

Question 10

What is pain localized to the back frequently attributed to?

Answer 10

Sinuvertebral nerve pain related to DRG compression

Question 11

What is the cause of disc degeneration with aging?

Answer 11

Proteoglycan in disc holds less water, decreases resilience and turgor

Question 12

Explain the progression of degenerative disc disease.

Answer 12

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

Question 13

What is often seen on MRI in degenerative disc disease, unique to this!

Answer 13

Vacuum disc phenomenon - ragged edged dark pocket, dark on T2 image

Question 14

What are the treatment options for patients with DDD?

Answer 14

Non-surgical: braces, medication, PT, weight loss, pain management

Surgical: Arthrodesis, or Disc Replacement

Question 15

What tests are usually done if DDD is suspected

Answer 15

MRI is first line (T2) will show loss of fluid in disc space

Meyelogram with contrast if MRI is contraindicated

Question 16

What is the most common cause of sciatica?

Answer 16

HNP - hydrostatic nature disrupted

Question 17

What level is the patellar tendon reflex?

Answer 17

L4

Question 18

What level is the Achilles reflex?

Answer 18

S1

Question 19

What is the motor strength level of tib anterior?

Answer 19

L4

Question 20

What is extension of the toes level?

Answer 20

L5

Question 21

What is the eversion motor level?

Answer 21

S1

Question 22

What modalities can be used for objective testing of the

Answer 22

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

Question 23

What are the indications for surgery with sciatica?

Answer 23

Failure to respond to conservative care
Muscle weakness (reflex changes)
Instability
Intractible pain

Question 24

What is cauda equina syndrome?

Answer 24

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

Question 25

Is cauda equina syndrome more common in men or women?

Answer 25

Men

Question 26

What is the clinical workup of cauda equina syndrome?

Answer 26

Can be the result of neurofibromas, hematomas, metastasis, fractures, herniations

EMERGENCY SURGERY - should be fixed within 48 hours to prevent further damage

Question 27

What is a hyperflexion vertebral fracture known as?

Common Etiology?

Answer 27

Chance fracture

Can be caused in an accident where seatbelt stopped the body from moving forward (waist belt)

Question 28

What is the most common insufficiency fracture seen?

Answer 28

Femoral neck fracture in osteoporotic patients

Question 29

Describe the gibbous deformity

Answer 29

Serious pathological kyphosis with anterior angulation/compression of the vertebral body.
Can cause serious neural issues including paraplegia

Question 30

Most common site of cervical radiculopathy?

Answer 30

C5-C6

Question 31

Which reflex and motor innervation tests are associated with the C5 level?

Answer 31

Deltoid Strength

Biceps Reflex

Question 32

Wich reflexes and motor tests are associated with C6?

Answer 32

Wrist Extension Strength

Brachioradialis Reflex

Question 33

What reflexes and motor tests are associated with C7?

Answer 33

Wrist Flexion/ Finger Extension Strength

Triceps reflex

Question 34

Whatt cervical fracture is commonly associated wtih the nuchal ligament?

Answer 34

Clay Shoveler’s fracture (C7 spinous process)

Question 35

What is a jefferson fracture?

Answer 35

Burst of C1

Question 36

Whats a hangmans fracture?

Answer 36

Broken Posterior arch of C2

Question 37

What is the most common cause of spinal infection

Answer 37

S. Aureus, 
disc space diseases caused by TB  
Could have epidural abscess
Most common in lumbar spine 
Severe back pain just shows up

Question 38

What maintains the hydrostatic pressure in the discs

Answer 38

Aggrican