Appproach To Thoracolumbar Complaint Flashcards
What are the two most life threatening conditions of concern/board based differential for thoracolumbar complaints?
Cauda equina syndrome and malignancy
What is spina bifida?
A birth defect that occurs when the spine and SC dont form properly
Type of neural tube defect
What are some etiologies/risk factors for spina bifida?
Folate deficiency, family history, increased body temp, obesity, DM and meds
What are the three classifications of spina bifida?
Occulta, meningocele and myelomeningocele
What is spina bifida occulta?
Mildest and most common type
Results in a small separation or gap in one or more of the bones of the spine
What is meningocele?
A sac of fluid comes through an opening in the baby’s back
Small gap in the spine but no opening or sac on the back
SC and nerves are usually normal
What is myelomeningocele?
Most severe type
Spinal canal is open along several vertebrae in the lower or middle back
Sac is formed exposing tissues and nerves making the baby prone to life threatening infections and may also cause paralysis
What is scoliosis?
Lateral curve of the spine greater than 10 degrees with vertebral rotation
What is the classification for scoliosis?
Congenital, neuromuscular or idiopathic (85%)
What is the most common form of scoliosis?
Adolescent idiopathic scoliosis (AIS)
What are some risk factors for scoliosis?
Females are 5-10x more likely
If both parents have AIS kids are 50x more likely to require tx than general population
Describe screening for scoliosis
Carries negligible risk to pts
Radiographs and referrals can lead to significant expense and risk of harm to pt
Tx of AIS detected by screening leads to moderate harms (e.g. unnecessary use of braces and referrals)
What is USPSTF?
Most cases detected through screening do not progress to clinically significant scoliosis
Scoliosis requiring surgery is likely to be detected without screening
What to look for upon inspection of scoliosis?
Body tries to keep eyes level Shoulder height difference Posterior scapula Crease at waist Leg lengths are usually equal
What is the Adam’s forward bend test?
PE for scoliosis
Pt stands and bends forward at the waist while assessing for symmetry of the back from behind and beside the pt
What is AIS evaluation based on?
Angle of trunk rotation (ATR) greater than 7 degrees and Cobb angle greater than or equal to 10 degrees is abnormal
What is needed for the official diagnosis of scoliosis?
Cobb angle measurement using radiography
Greater than 10 degrees
What is a Risser sign-progression prediction?
The amount of calcification present in the iliac apophysis and measures the progressive ossification from anterolaterally and posteromedially
The higher the Risser sign the less the what?
Likely their scoliosis will progress
What are the red flags when evaluating curving of a back?
Onset before age 8
Severe pain
Rapid curve progression >1 degree per month
Unusual left thoracic curve (convex to the left)
Neurological deficits or findings
What is left thoracic curvature associated with?
Additional pathology including spinal cord tumors, neuromuscular disorders, etc
Many first episodes of low back pain occur when?
Between 20-40 years of age
Many are self limited and resolve with little intervention
Acute low back pain (LBP) can be defined as what?
6-12 weeks of pain between the costal angles and gluteal folds that may radiate down one or both legs (sciatica)
Often nonspecific and therefore cannot be attributed to a definite cause
What are some common causes of low back pain?
Somatic dysfunction Herniated disc Cauda equina syndrome Spondylolisthesis, sponylolysis Compression fractures
What is the clinical presentation for compression fractures?
Most common in elderly whites females with point tenderness at spine level, pain worsens with flexion and while pulling up from a supine to siting position to standing
What are some causes/risks for compression fractures?
Osteoporosis
Other causes include injuries to the spine and tumors in the spine
What is a herniated disc?
A fragment of the disc nucleus that is pushed out of the annulus into the spinal canal through a tear or rupture in the annulus
What is the clinical presentation for a herniated disc?
Arm or leg pain, numbness, tingling, weakness
Pain will often originate from the lumbar spine and radiate down the leg into the foot
Sharp burning pain
Weakness and decreased sensation
What are some causes or risk for herniated discs?
Obesity, occupation, genetics, smoking
Spine structures refer to what?
Thigh region but rarely below the knee
Sacroiliac joint pain often refers to what?
Pain to the thigh but can also radiate below the knee
Red flags are often used to distinguish what?
A common, benign episode from a more significant problem that requires urgent work up and tx
What are the red flags for low back pain?
Trauma Unexplained weight loss Neurological sx Age > 50 Fever IVDU Steroid use Hx of cancer TUNAFISH
What is cauda equina syndrome?
Large central disc herniation compressing the tail of the lumbar spine casing compression of sacral nerve roots
What is lumbosacral strain?
An injury to either muscle or tendon
What is lumbosacral sprain?
The stretching or tearing of a ligament
What is psoas syndrome?
An uncommon and misdiagnosed condition that can appear as refractory lower back pain (pain that stays even after Tx) accompanied by other sx
What is short leg syndrome?
Refers to a discrepancy in leg lengths resulting in chronic leg and back pain
Pts with scoliosis will have what?
A lateral bending of the spine but the curve will cause spinal rotation and eventually a rib hump which is visible on examination
Irritation, compression or impingement of the lumbar root often results in what?
More leg pain than back pain
L1-3 nerve root pain will radiate to the hip and/or thigh
L4-S1 nerve root pain will radiate below the knee
Which reflex is tested at L4?
Patellar reflex
What nerve root tests for great toe sensation and heel walk?
L5
Which reflex is tests the S1 nerve root?
Achilles reflex and toe walk
Pts with back pain in the primary care setting tend to have what?
One or more red flags but rarely have a serious condition
Therefore physicians should rely on a comprehensive clinical approach rather than solely on a checklist of red flags
What are the signs and sx of cauda equina syndrome?
Pain similar to herniated disc (low back pain) that radiates down the leg, numbness around the anus and loss of bowel or bladder control
What does impingement of S2-4 cause?
Bowel dysfunction (decreased rectal tone), bladder dysfunction, sexual dysfunction and saddle anesthesia
What is imperative to cauda equina syndrome?
Emergent surgery
Delay can result in irreversible paralysis
What is the clinical presentation for lumbosacral strains and sprains?
Pain that gets worse when you move
Muscle cramping or spasms
Decreased function or ROM of the joint
May feel a pop or tear at the time of injury
What is seen on the exam for lumbosacral strains and sprains?
Discrete tender points in the lumbar tissue/paraspinal muscle region
No neurological deficits
What are some causes for psoas syndrome?
Injury/shortening/spasm of the iliopsoas muscle
More common in athletes, runners, and those engaged in polymetric jumping exercises
Initiated by positions that shorten the psoas, sitting, bending, getting up quickly from squatting position, desk jobs
What is seen on the exam for psoas syndrome?
Tender point at iliacus (medial to ASIS)
+Thomas test and +FABER
Psoas syndrome can cause a variety of Sx including what?
Lower back pain (MC sx)
Difficulty/pain when trying to stand in a fully upright position
Pain in the buttocks
Radiation of pain down the leg
What are the two types of short leg syndrome?
Anatomical and functional
What is anatomical short leg?
When one leg is longer and can be corrected with a heel lift in the shoe of the short leg
What is functional short leg?
An apparent short leg although structurally both legs are the same length when measured
What is sacroiliitis?
An inflammation of one or both of your sacroiliac joints
What is the presentation for sacroiliitis?
Can cause pain in your buttocks or lower back and can extend down one or both legs
Prolonged standing or climbing can worsen the pain
Bearing more weight on one leg than the other, running and taking large strides can worsen the pain
What are the signs and sx for sacroiliitis?
+FABER test with buttock pain, not groin pain
What is piriformis syndrome?
A condition in which the piriformis muscle spasms and causes buttock pain
What is the presentation for piriformis syndrome?
Increasing pain after sitting longer than 15-20 mins
Pain/paresthesia radiates to posterior thigh and usually stops above the knee
Pain improves with ambulation
What are the signs and sx for piriformis syndrome?
Positive leg roll with sciatic notch tenderness
Unlike sciatica from disk herniation piriformis syndrome is exacerbated by active external hip rotation*
What is spinal stenosis?
A narrowing of the spaces within your spine which can put pressure on the nerves that travel through the spine
Occurs most often in the lower back and neck
Neurogenic claudication describes what?
A combination of low back pain, leg pain, numbness and motor weakness that starts or intensifies on standing or walking and is eased by sitting in lying down
Not all pts will exhibit this
Describe the clinical presentation for spinal stenosis
Mainly affects people over 50 years old
May have a dramatic presentation with low back pain, difficulty in walking, changes in urinary functions in addition to root sx such as numbness, burning and heaviness of the legs
Leg pain is greater than back pain
What is spondylosis?
Age related wear and tear of the spine due to encroachment on the spinal canal with potential for radiculopathy and myelopathy
Often related to formation of osteoarthritis
Presents with pain, stiffness and occasional numbness
What is spondylolysis?
A specific defect in the connection between vertebrae without anterior displacement of the vertebral body
Can lead to small stress fractures in the vertebrae
Common cause of low back pain in children and MCC of low back pain in people younger than 26
Can have no sx or sx that present during teenage growth spurt
Low back pain is most common sx
How is a Dx of spondylolysis made?
With an oblique view of the lumbar spine
Fracture of par interarticularis described as Collar of Scotty Dog usually at L5/S1
What is spondylolisthesis?
Condition where the vertebral body slips in relation to the one below at par interarticularis (usually between L5 and S1)
Low back pain is the MC sx when sx do occur
What is seen on the exam when evaluating for spondylolisthesis?
On palpation of the lumbar spinous process there is a “step off” sign that indicates spondylolisthesis
As seen on the lateral view of an X ray
What are examples of CT disease?
RA and SLE
What are examples of spondyloarthropathies?
Arthralgia or polyarthralgia
Arthritis, reactive arthritis and psoriatic arthritis
Ankylosing spondylitis
What is arthritis?
A diagnosis and not a sx
Diagnosis requires the physical signs of articular inflammation or the physical or X ray signs of OA
What is ankylosing spondylitis?
MC form of spodyloarthropathy
Related to the prevalence of HLA-B27
Most often affects white males between 15-40 years of age
Bamboo spine will be seen on an X-ray of the lumbar spine
What is reactive arthritis?
Often develops after an infection in the urinary tract or GI system
More common in males
Related to Reiter’s syndrome (eye, urethra and joint inflammation)
What is psoriatic arthritis?
Affects major joints of the body and is typically asymmetric
Usually happens to people with a skin condition called psoriasis
Nail pitting is usually seen
Describe malignancy (cancer)
Risks include age, FHx, smoking and cancers that metastasize to bone
Presentation includes pain that worsens in the prone position, recent weight loss and fatigue
Upon exam typically have spinous process tenderness with metastasis to the spine
What is vertebral diskitis/osteomyelitis?
Inflammation that develops between the IV discs of your spine
Major risk includes IV drug abuse
Presents with severe back pain with or without fever
Upon exam there will be constant pain, spinous process tenderness and often no fever
What is the Choosing Wisely imaging for low back pain?
Don’t do imaging for LBP within the first 6 weeks unless red flags are present
