9. Spine Medicine & Spinal Orthosis Flashcards
Innervation of facet joint ππ
Cervical: Medial branch at the level and the below level (C1 facet from C1, 2)
Thoracic & Lumbar: Medial branch at the level and the above level (L5 facet from L4, 5)
Face joint and relation to spine mobility. ππ Dr. Jamal & Dr. Abdulrazaq
Cervical Vertebra
- Free flexion and extension
- Limited bending and rotation
- Horizontal facing facet
Thoracic Vertebra
- Free lateral flexion
- Restricted flexion and extension
- Limited rotation
- Frontal/Coronal aligned facet joint
Lumbar Vertebra
- Good flexion, extension and lateral flexion.
- Limited rotation.
- Sagittal facet joints.
Components of intervertebral disc ππ
Three distinct components
- Central nucleus pulposus (NP)
Type II collagen
- Peripheral annulus fibrosus (AF)
Type I collagen
- Two vertebral endplates (VEPs).
What is the function of proteoglycan? Bonus Q
The major biological function of proteoglycans derives from the physicochemical characteristics of the glycosaminoglycan component of the molecule, which provides hydration and swelling pressure to the tissue enabling it to withstand compressional forces.
What is the function of collagen? Bonus Q
Collagen makes up articular cartilage, the tissue that covers the ends of bones at the joints and allows them to move smoothly against one another and provides bone, tendons and ligaments with tensile strength and skin with elasticity
Innervation of intervertebral disc ππ EXAM 2019
- Anterolateral part of the annulus fibrosis is innervated by ventral rami and gray rami communicans
- Posterior part of the annulus fibrosis is innervated by sinuvertebral nerves
Cuccurullo 4th Edition Chapter 4 MSK pg284
List 3 possible sites for needle insertion when doing epidural steroid injection ππ
- Transforaminal approach
- Interlaminar approach
- Caudal approach
Ref: Cuccurullo page 331 + Braddom
Explain spine ROM (Flex-Ext-Bend-Rotate) in each region of the vertebra ππ Dr. Abdulrazaq
Cervical
- Extension Occipital-C1 junction.
- Axial rotation C1βC2 levels
- Lateral bending C3βC4 and C4βC5 levels.
Thoracic region
- Axial rotation occurs mostly at the T1βT2 level, decrease toward the lumbar spine.
- Lateral bending is fairly evenly distributed throughout the thoracic levels.
- Flexion and extension T11βT12 and T12β L1 levels.
Lumbar region
- Lateral bending predominantly at the L3βL4 level.
- Insignificant axial rotation in the lumbar spinal segment.
Atlanto-Axial joint biomechanics
The odontoid process lies anterior to the spinal cord as a pivot for the rotation of the head.
The C1 vertebra, carrying the cranium, rotates on odontoid process.
The craniovertebral joint between the atlas and the axis is called, the atlanto-axial joint.
Name the major ligaments of the spine and the spine motions they resist ππ MOCK
- Anterior longitudinal ligament β extension
- Posterior longitudinal ligament β flexion
- Ligamentum flavum and facet joint β flexion
- Interspinous and supraspinous ligaments β flexion
PMR Secrets β 3rd edition β page 16
Define Denis Three Column Model. ππ
EXAM Mention the βmiddle columnβ components of Denisβs model 3 Marks ππ MOCK
When do you consider bracing or not? which type of brace? ππ Dr. Jamal
MIDDLE COLUMM
- posterior longitudinal ligament
- posterior one third of the vertebral body
- posterior one third of the annulus fibrosis
Braddom (ch. Spinal cord injuries β spinal mechanics and stability)
BRACING
π‘ When the middle column and either the anterior or posterior column are compromised, the spine may be unstable
- Unstable fracture require HALO
- Stable fracture require less restrictive Orthosis (Minerva- Four Poster - SOMI)
Mention 3 types of odontoid fractures ππ EXAM
Type 1 is a fracture through the tip of the odontoid
Type 2 is a fracture through the base of the odontoid
Type 3 is a fracture that extends from the base of the odontoid into the axis proper
Indication & Contraindication of Soft & Rigid CO
Soft CO:
- Symptomatic treatment of soft tissue injuries of the neck (i.e., whiplash injury)
- Psychological reassurance
- Kinesthetic reminders to limit cervical range of motion;
- Provide some warmth and comfort
Rigid CO:
- Mid-cervical bony or ligamentous injuries
- Stable cervical fractures
- Postoperative stabilization
- Anterior cervical fusion
- Anterior discectomy
- Patients dealing with tracheostomy
- Post-halo removal
Contraindication
- Spinal instability
List 4 Complications of cervical orthosis ππ
- Limit vision to the walking ground β tripping hazards, that is toys on the floor, cracks in the sidewalk, pets, loose rugs, etc β managed by home visit via OT
- Decrease in maximal mouth opening β dysphagia β aspiration pneumonia (head elevation, slight cervical extension, and limited chin tuck)
- Reduction in tidal volume
- Affects the driving performance (Increase blind spot, canβt look to side lane) β drive slowly
- Pressure ulcer formation (occipital protuberance, mandible (chin), clavicles, and ears)
- Excessive perspiration
- Marginal mandibular nerve palsy
Name, Type, Indication, Restriction, Disadvantages, Precaution ππ
SOFT CERVICAL COLLAR
Type
- Soft CO
Indication
- Symptomatic treatment of soft tissue injuries (whiplash injury) for 10 days
Restriction:
- 75% flexion/extension 90% Lateral bending 80% Rotation
Disadvantages
- Muscle atrophy
- Psychological dependency
- Delayed return to work (twice as long)
- Perceiving more pain and disability in both 6 weeks and 6 months post injury.
Precaution
- Not to be used in fractures (both stable or unstable)
- Does not provide structural support
Cuccurollo 4th Edition Chapter 6 P&O pg527
Name, Type, Indication (1)
Thomas Collar
Type
- Rigid CO
Indication
- Soft tissue injuries
Cuccurollo 4th Edition Chapter 6 P&O pg
Name, Type, Restriction, Indication (2)
Philadelphia (Cheese)
Type
- Rigid CO
Indication
- Cervical sprains, strains, or stable fractures.
- After anterior cervical fusions and anterior diskectomy procedures
- Wean off from more restrictive orthoses to limit sudden strain on the neck
Restriction
- 30% flexion/extension 65% bending 45% rotation
Contraindication
- Unstable spine
- Lose effectiveness at higher and lower cervical levels (occiputβC2 and C6βC7)
Cuccurollo 4th Edition Chapter 6 P&O pg527
Braddom 6th Edition Chapter 13 Spinal Orthosis pg252
Name, Type, Benefits, Indication (3-6)
Variants of the Philadelphia collar
Name: Aspen, Vista, Miami J, Malibu
Type: Rigid Cervical Collars
Benefits
- Cervical strain.
- Postoperative stabilization
- Post-halo removal.
Name, Type, Restriction, Indication, Contraindication
Sternal Occipital Mandibular Immobilizer (SOMI) Ψ³Ω ΩΨ©
Type
- Cervicothoracic orthosis (CTO)
Restriction
- 25% flexion/extension 65% bending 35% rotation
- Effective in limiting C1-C5 flexion
- Less effective in limiting extension
- Appropriate option for bedridden patients
Indication:
- Cervical sprains, strains, or stable fractures with intact ligaments.
- Cervical arthritis
- Postsurgical fusions
- RA: Atlantoaxial instability and neural arch fractures (Better than Philadelphia)
Contraindication:
- Unstable fractures with ligament instability.
Cuccurollo 4th Edition Chapter 6 P&O pg527
Braddom 6th Edition Chapter 13 Spinal Orthosis pg253
Name, Description, Indication
Four-Poster Orthosis
Type
- Cervical Thoracic Orthoses
Restriction
- 20% flexion/extension 45% bending 30% rotation
- Adjustable length via anterior or posterior posters
Indication:
- Sprains, strains
- Stable fractures with intact ligaments
- Arthritis
Cuccurollo 4th Edition Chapter 6 P&O pg528
Name, Restriction, Indication, Contraindication
Yale Orthosis
Type
- CTO
- Extended Philadelphia Collar = Higher and Lower than Philadelphia
Restriction
- 12% Flexion/Extension 50% Bending 20% Rotation
Indication:
- Most restriction of ROM occurs below the level of C5
- Sprains, strains
- Stable fractures with intact ligaments
Contraindication
- Insufficient for immobilizing the unstable spine
- Lose effectiveness at higher and lower cervical levels (occiputβC2 and C6βC7)
Cuccurollo 4th Edition Chapter 6 P&O pg528
Name, Restriction, Indication, Advantages, Disadvantages
Minerva Body Jacket / Minerva Ω ΩΩ
Type
- CTO
Restriction
- 15% Flexion/Extension 15% Bending 0% Rotation
Advantages:
- Forehead band provides good control of all cervical motions
- Lighter weight than the halo vest
- No pins (no βinvasiveβ supports that carry risks of infection and slippage)
Indications
- Management of unstable cervical spine
- Preferred over halo due to β comfort β weight
- Allows early mobilization for rehabilitation, while providing the necessary stability
Disadvantages
- Less restriction of motion compared to a halo vest
Cuccurollo 4th Edition Chapter 6 P&O pg528-529
Name, Restriction, 4 Indication, 2 Contraindication, Guide, Most Common Complication. π
Halo Vest & Lerman Non Invasive Halo
Type
- CTO
Restriction:
- Invasive 4% Flexion-Extension 4% Bending 1% Rotation
- Non-Invasive 12% Flexion-Extension 8% Bending 3% Rotation
Indication
- Unstable cervical fractures: C1 Jefferson - C2 Hangman - C2 Odontoid
- Postoperative management.
- Primary method for conservative upper and mid-cervical fracture.
- Surgical intervention is contraindicated
- Alternative for patients patient refusing operative
Contraindication
- Stable fractures or when less invasive management could be used.
- Extremely soft skull might not tolerate the pin placement.
Guides
- It is worn for 3 to 4 months.
- Increasing the strap tension decreased the motion, especially in lateral bending
- Weight loss due to diuresis or changes in appetite can affect chest circumference, and strap adjustments may be indicated
- Patients and caregivers should be strongly discouraged from arbitrarily manipulating these straps without consulting the physician.
- Patientβs shoulder abduction to 90 degrees and avoid shoulder shrugging
- Cleaning with sterile cotton-tip applicators with antimicrobial soap and normal saline.
- Avoid povidone-iodine (Betadine), hydrogen peroxide, and alcohol: risk of pin corrosion, interference with bacterial autolysis, ineffective infection reduction, and disruption of the healing process.
Pin loosening (Most Common)
- Subjectively, the patient may report clicking/grating/creaking sounds, a sensation of looseness, pain at the pin site, headache, or halo vest movement.
- Loose pins are either retightened or removed and reinserted elsewhere
Cuccurollo 4th Edition Chapter 6 P&O pg
Complications Associated With Halo Vest Use. 8 marks ππ EXAM 2017-2018
- Pin loosening (most common)
- Failure to develop spinal stability after wearing the halo
- Pressure sore development
- Pin site pain
- Pin penetration of the skull
- Pin tract infection
- Brain abscess
- Local osteoporosis
- Forehead scarring
- Acute equilibrium impairments
- Dysphasia
- Halo ring migration
- Cranial nerve palsy
- Brachial plexopathy
- Reduction in vital capacity
- Loss of spinal reduction while wearing a halo
Cuccurollo 4th Edition Chapter 6 P&O pg530 Table 6-16
EXTRA
- Temporalis muscle penetration
- Pin site pain during mastication
- Epileptic seizures.
DeLisa 5th Edition Chapter 77 Spinal Orthosis pg2088 Table 77.4
Name, Type, Indication, Contraindication ππ
What are the three factors to decide on wearing this type of spinal orthosis?
Milwaukee Brace
Type
- CTLSO
Indication & Contraindication Based on:
- Degree of curve
- Apex
- Skeletal Maturity
Cuccurollo 4th Edition Chapter 6 P&O pg532
Name, Type, Restriction, Indication, Contraindication (1&2)
Jewett Brace & CASH
Type:
- Flexion control TLSO
Restriction:
- Prevent only flexion
- Jewett offer more lateral support than the CASH
Indication β Bend spine
- Compression fracture of the thoracolumbar (TL) spine
- For use with stable fractures of T3 to L3 with less than 50% compression
- Thoracolumbar Scheuermannβs disease
- Thoracic osteoporotic kyphosis (with limited efficacy)
Contraindication:
- Unstable fractures
- Burst fractures
- Spondylolisthesis.
Cuccurollo 4th Edition Chapter 6 P&O pg531
Braddom 6th Edition Chapter 13 Spinal Orthosis pg254-255
