2.1. Approach to Thoracolumbar Spine Flashcards
7 things you palpate for on the spine
1-4: TART
- Spinal column
- Paraspinal muscles
- Muscles of back
Why do you percuss?
See most tender points on exam
What can percussion on examination identify?
- pain points
- discrete areas of fx (low sensitivity, mod specificity)
Differential Diagnosis considerations with thoracic or lumbar spine complaint (5)
- compression fx
- osteomyelitis
- muscle spasm
- strain (ligaments)/sprain (muscles)
- SD
scoliosis definition
abnormal curvature of the spine
early onset scoliosis
<10 years old
- kids are still growing so it can affect more than just the spine (malformed ribs affecting lung development)
- more promise for intervention the earlier its caught
Adolescent idiopathic scoliosis (AIS)
- most common form
- affects 4/100 children between 10-18, genders equally affected
- by 10 yo, spinal growth slows so if you have a significant degree of spinal curvature at this point, curve may continue to progress into adulthood
what spinal curvature defines scoliosis
Cobb angle > 10 degrees
Epidemiology of AIS
- Only 10% of AIS require treatment (0.3% of population)
- Genders equally affected
- Risk of curve progression (and treatment) is 10x higher in female than male
Causes of adult scoliosis
- de novo degenerative
- profession of congenital, early onset, or adolescent idiopathic scoliosis
- secondary to another condition: paralysis, trauma, spinal surgery
- adult spinal deformity (scoliosis, kyphosis, lordosis, spondylolisthesis)
What 5 landmarks do you use to screen for scoliosis?
- Difference in height fo shoulders or scapulae
- asymmetry of waistline
- asymmetry in distance arms hang from trunk
- head shifter to one side and not centered over sacrum, “trunk shift”
- A “plum line” dropped from spinous process of C7 (should pass thru gluteal cleft)
How do you perform a forward bending test for scoliosis?
- pt bends forward with knees extended
- sidebends left and right while physician monitors posteriorly for accentuation or improvement of spinal curvature
Spondylolysis
stress fracture or detect in vertebral arch
spondylolisthesis
displaced fracture (spondylolysis) where vertebral body slips forward over another -different types: degenerative, isthmus, dysplastic, traumatic, patholgic
Spondylitis
inflammation of spinal joint
spondylosis
painful condition of spine resulting from degeneration of IV disks
3 common treatments for scoliosis
- observation
- bracing: dependent on Cobb angle, deformity, progression risk
- surgery: usually angle >39-50 degrees
2 types of braces for scoliosis
- underarm brace, “Boston brace”
2. under-chin extension, “Milwaukee brace”
4 common surgeries for scoliosis
- posterior spinal fusion, instrumentation, and bone graft
- anterior spinal fusion and instrumentation
- combination of anterior and posterior
- growth modulation techniques
What is the curvature, risser scale number, and success rate of the early intervention stage for scoliosis?
Curvature: <30 degrees
Risser: 0-2
Success rate: 100%
What is the curvature, risser scale number, and success rate of likely to progress intervention stage for scoliosis?
Curvature: 30-49 degrees
Risser: 0-3
Success rate: 92%
What is the curvature and success rate of above surgical threshold intervention stage for scoliosis?
Curvature: >50 degrees
50% success rate
What time length is considered acute low back pain?
< 4-6 weeks
Symptoms of cauda equina
- progressive motor or sensory defect
- saddle anesthesia (buttocks, perineum and inner surfaces of the thighs)
- bilateral sciatica or leg weakness
- difficulty urinating, including retention
- bowel or bladder incontinence
What time length is considered subacute low back pain?
6 weeks to 3 months
What are red flag findings for spinal pathology for onset <20 years or > 55 years?
- unrelenting thoracic pain at night, unrelated to time or activity
- widespread neuro symptoms
- unexplained weight loss
- feeling unwell, fever, chills
- significant trauma
- penetrating wound near spine
- structural spinal deformity
- Hx: osteoporosis cancer or strong suspicion of current cancer, recurrent infection (UTI), HIV
Why is IV drug use pertinent with low back pain complaints?
highly associated with acute bacterial endocarditis –> osteomyelitis
Why is steroid use pertinent with low back pain complaints?
decrease immune response, could lead to things like osteoporosis which would make bones weaker
What is the sensitivity and specificity for diagnosis of compression fractures >50 years of age?
sensitivity: 84%
specificity: 61%
pseudoclaudication
painful cramps that are not caused by PAD but rather by spinal, neurological or orthopedic disorders such as spinal stenosis, diabetic neuropathy, or arthritis
Ankylosing spondylitis
- typical onset <40 years (sens: 100%, specificity: 7%)
- pain was not relieved laying supine (sens: 80%)
- morning back stiffness (sens: 64%)
- pain duration >3 months (sens: 71%)
Sensitivity vs specificity
- sensitivity: ability of a test to correctly identify those with the disease (true positive rate)
- specificity: ability of the test to correctly identify those without the disease (true negative rate)
vascular vs spinal claudication
arterial circulatory insufficiency (known as vascular claudication) or spinal stenosis (known as neurogenic or pseudo-claudication).
Patients with either condition will generally see the leg pain go away with rest, but spinal stenosis patients usually must sit for a few minutes to ease the leg pain and often the accompanying low back pain. Vascular claudication will dissipate simply if the patient stops walking.
common symptoms of lumbar spinal stenosis
- gradual development over time
- non-continuous pain that comes and goes
- occurring during specific activities like walking) and/or in positions like standing upright
- relieved by rest, whether sitting or lying down and/or getting into any flexed forward position
Sciatic nerve pain or Sciatica symptoms
sharp, burning nerve pain that runs from lower back or hip, down back of leg, to foot
-from injury or compression of sciatic nerve
When evaluating for low back pain, what 4 structures will you feel for in the palpation part of the exam?
- spinous processes of thoracic and lumbar spines
- transverse processes “ “
- paraspinal muscles
- Sacroiliac joint
* evaluate for TART in each of these areas
What type of pathology would one find “step-offs”?
spondylolisthesis - forward slippage of one vertebra, which may compress spinal cord
What could tenderness over the sacroiliac joint be an indication of?
sacroilitis and ankylosing spondylitis
What reflexes and their associated nerve root would you be testing for during a low back complaint evaluation?
- patella, L4
2. achilles tendon, S1
What would the straight leg raise (Laseque) test be evaluating for?
lumbosacral radiculopathy (usually from a herniated disc) and/or sciatic neuropathy
How would one perform the straight leg raise (Laseque) test?
- patient supine
- passively flex patients ipsilateral hip with knee extended
- add dorsiflexion to increase dural tension in low lumbar and high sacral levels
What would be considered a positive test for the straight leg raise (Laseque) test?
presence of worsening radicular pain radiating to ipsilateral leg, especially between 30-60 degrees and worse with dorsiflexion
tightness is common so don’t associate it as radiating pain for a positive test
What could a positive sign at >70 degrees during a straight leg raise test specifically indicate?
mechanical low back pain due to muscle strain or joint disease
What could a positive sign at >15 degrees during a straight leg raise test specifically indicate?
IT band contracture
What physical findings would make sciatica diagnosis 5x more likely?
ipsilateral calf wasting and weak dorsiflexion
How would one perform a contralateral (crossed) straight leg raise test?
- patient supine
- passively flex pt’s contralateral hip with knee extended
what would be considered a positive test while performing the contralateral (crossed) straight leg raise test?
presence or worsening radicular pain, radiating into contralateral leg, especially between 30-60 degrees
What would a positive contralateral (crossed) straight leg raise test possibly indicate?
lumbosacral radiculopathy (usually from herniated disc) and/or sciatic neuropathy
What spinal curvature increases with age?
thoracic kyphosis
What helps bring the head back to midline in patients with scoliosis?
lateral and rotatory curvatures of the spine
What patients/conditions present with unequal shoulder height?
- scoliosis
- sprengel deformity of scapula from attachment of extra bone or band
- “winging” of scapula from loss of long thoracic nerve innervating serrates anterior and contralateral weakness of trapezius
What patients/conditions present with unequal height of iliac crest or pelvic tilt?
- unequal leg length
- scoliosis
- abduction or adduction of hip
- herniated lumbar disc
What would deformity of theca on forward bending, especially when height of scapula is unequal suggest?
scoliosis
What would persistence of lumbar lordosis suggest?
muscle spasm or ankylosing spondylitis
What conditions is decreased spinal mobility common in?
osteoarthritis and ankylosing spondylitis
What is caudal equine syndrome?
condition of spinal nerve root compression usually by massive disc protrusion, fracture/trauma, or tumor that results in bowel/bladder dysfunction
*requires EMERGENT management and surgical decompression within 48 hours, or permanent nerve damage can remain
Meningocele
meninges forced out between vertebra
-surgically repaired with usually no neurological damage
Myelomeningocele
- most common
- unfused portion of spinal cord protrudes through opening
- very severe (permanent) neurological complications
Ferguson’s angle
Normal: 30-40 degrees
-used to evaluate stability of lumbosacral region by equating angle between: lumbosacral angle and the lumbar gravity line
what muscles are involved in flexion at hips?
- psoas major
- psoas minor
- quadratus lumborum
- abdominal muscles attaching to anterior vertebrae (internal or external obliques or rectus abdominis)
what muscles are involved in extension at hips?
-deep intrinsic back muscles (erector spina and transversospinalis)
what conditions would spinal “step-offs” occur?
spondylolisthesis
what is tenderness over the sacroiliac joint common in?
sacroilitis and ankylosing spondylitis
what is radiculopathy commonly called?
pinched nerve
where do >95% of disc herniations occur and why?
L5-S1 because the spinal angles are sharply posterior
what would signs of ipsilateral calf wasting and weak dorsiflexion highly suggest?
sciatica
why is diagnostic accuracy of the straight leg test limited for dx radiculopathy?
low specificity (high sensitivity)
What are classic presentations of caudal equina?
- low back pain
- bowel/bladder dysfunction
- sensory loss of perineum “saddle anesthesia” and decreased anal sphincter tone
- bilateral sciatica and leg weakness
