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MSK > Back > Flashcards

Back Flashcards

1
Q

How is back aligned

A

Cervical and lumbar lordosis

Thoracic and sacral kyphosis

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2
Q

What are the vertebrae in the back

A 
7 cervical (8 nerve roots)
12 thoracic 
5 lumbar
5 sacral (fused) 
4 coccygeal (variable)
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3
Q

What is scoliosis

A 
Abnormal lateral curvature 
Usually lumbar and thoracic 
2nd to congenital 
- Neuromuscular - spina bifida / Marfan
- NF 
Idiopathic muscle spasm
Tumour
Osteoporosis 
Ankylosisn spondylitis 
Infection
Friedrich ataxia
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4
Q

What is kyphosis

A 
Abnormal increase in thoracic  curvature 
Often due to osteoporosis
Congenital 
Spina bifida 
Wedge fracture
TB
Pagets 
AS
Malignancy
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5
Q

What bones make up vertebrae

A 
Vertebral body
Vertebral arch (pedicle + lamina) 
Spinous process
Transverse process
Articular facets + process
Vertebral canal in centre
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6
Q

What transmits vertebral artery

A

Foramen transversarium

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7
Q

What do cervical vertebrae have

A

Bifid spinous process except C1 and C7

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8
Q

What is atlas joint

A

C1
Atlanto-occipital joins to skull
Allows nodding and lateral flexion

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9
Q

What is fracture in C1 called

A

Jefferon

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10
Q

What is axis joint

A

C2 / Odontoid process

Atlanta-axial joint for rotation

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11
Q

What type of joint = facet

A

Synovial

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12
Q

What type of joint is costal

A

Synovial

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13
Q

What ligaments in spinal cord

A

ALL (along front of vertebral body)
PLL (in front of spinal cord and back of vertebral body)
Ligamentum flavum (between lamina)
Interspinous and supraspinous (between spinous procesS)
Intertransverse (between transverse process)

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14
Q

What type of joint is IV disc

What is action and how do they fail

A

Secondary cartilaginous

Resist rotational movement so fail on twisting movement

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15
Q

What makes up IV disc

A 
Annulus fibrosus (tough outer layer) 
Nucleus pulposus (gel core)
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16
Q

What are superficial muscles of back

A

Trapezius
Lat dorsi
Levator scapular
Rhomboid

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17
Q

What are deep muscles of the back

A

Erector spinae

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18
Q

How are bone mets common in vertebrae

A

Bateson’s plexus = extensive plexus aroundd vertebae

No valves so IVC goes to plexus then into vertebrae

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19
Q

What is adolescent idiopathic scoliosis

A

Most common spinal deformity which commonly affects girls
Curvature increases as grows
Earlier onset = worse deformity

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20
Q

How do you Rx

A

Refer to clinic

Braces may slow down

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21
Q

What are complications

A

Pain
Cosmesis
Impaired lung function

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22
Q

How do you measure degree

A

Cobbs angle

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23
Q

What must you exclude if painful

A

Osteoid osteoma
Spondylolisthesis
Spinal tumour

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24
Q

What are causes of back pain in <50 and >50

A 
<50
Prolapse
Trauma / fracture
Ankylosing spondylitis
Pregnancy
Malignancy 
>50 
Degenerative
Osteoporosis
Paget's 
Malignancy
Myeloma
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25
What causes back pain 6 categories
Degeneration - spinal stenosis / spondylosis / vertebral collapse TRAUMA Mechanical - strain / trauma / prolapse / spondylolisthesis Inflammation - AS / Paget's Neoplastic Infection - TB / abscess Peripheral arterial disease
26
What are red flags which require investigation
``` <20 or >55 Acute onset in elderly Constant or progressive Nocturnal Thoracic pain Morning stiffness Bilateral or alternating leg pain Fever / weight loss / night sweats Current or recent infection Malignancy Hx Neurological e.g. sciatica Sphincter disturbance Immunosuppression IVDA Leg claudication or exercise related leg weakness / numb ```
27
What does claudication / exercise related weakness suggest
Spinal stenosis
28
What does UMN signs suggest
Cord compression
29
When do you do X-ray
If suspect malignancy or osteoporotic fracture otherwise do MRI esp if neurological / sensory deficit CT if don't suspect osteoporosis
30
When do you do MRI and bloods
>4 weeks Red flags Or suspecting sinister causes
31
What bloods
FBC, CRP, ESR, Calcium, phosphate, ALP, U+E, PSA, myeloma screen
32
What are non MSK causes of back pain
``` Duodenal ulcer AAA MI Systemic TB Renal colic Pyelonephtiis Neoplasia Bone mets ```
33
What is non specific back pain
Lower back strain or degenerative Non uncommon to develop sciatica Goal is to exclude sinister causes
34
How do you Rx
``` Avoid rest Analgesia - opioids may be needed NSAID = 1st line Muscle relaxant if spasm persists Physio ```
35
If progressive neuro signs / disabling pain despite physic and analgesia
Specialist within 2 weeks
36
If disabling pain >2 weeks but no red flags
Early physio | Steroid injection
37
What is cauda equine syndrome
Compression of caudal equina | Surgical emergency
38
What causes cauda equina
``` Large prolapse Herniation lumbar disc Extrinsic tumour Primary cord tumour Bone mets Myeloma Spondylosis Spinal stenosis Abscess Trauma Spinal surgery Epidural injection Spina bifida ```
39
What are the symptoms of cauda equina
``` LMN signs Sudden onset back pain Alternating or bilateral root pain down legs Buttock and leg pain Saddle anaesthesia Poor anal tone Urinary retention Faecal incontinence Flaccid paralysis ```
40
How do you differentiate from cord compression
Cord usually UMN signs = spastic paralysis and hyperreflexia | Hyporeflexia and flaccid in cauda equina
41
How do you Dx cauda equina
MRI within 4 hours if suspect Lumbar CT if CI PR shows loss of anal tone
42
What must you do in everyone presenting with back pain
Comment for absence of cauda equina signs
43
How do you treat cauda equina
Neurosurgery within 48 hours
44
What are complications of cauda equina
Permanent damage Paralysis Incontinence Difficulty walking
45
When should you have a high index of suspicion
Post op spinal patients | Increasing leg pain and urinary retention
46
What causes acute cord compression
Same as cauda equina but compresses cord causing UMN signs
47
What are the symptoms of cord compression
``` Bilateral pain down legs Pain in back Bilateral leg weakness Numbness LMN signs at level of compression UMN and sensory loss below ```
48
What is a late sign
Sphincter and bladder disturbance
49
What should you remember about reflexes
Reflexes and tone may be reduced in acute phase due to shock
50
How do you investigate cord compression
``` MRI whole spine within 24 hours - May present with multiple lesions at different level Biopsy any mass CXR FBC, U+E, LFT, ESR, B12, syphillis, PSA Serum electrophoresis for myeloma ```
51
How do. you Rx
BED REST Urgent Rx prevents lasting damage Laminectomy for prolapse Urgent dexamethasone for malignancy + PPI DVT prophylaxis Refer urgently to spinal surgery to see if suitable otherwise RT for tumour Decompression of abscess
52
What can spinal tumour be
Primary or metastatic Lymphoma / Myeloma Cord / meninges / nerves / bone
53
What are the Sx
``` Same as cord compression LMN signs at level UMN signs and sensory loss below Pain Bladder and bowel dysfuncion Peripheral nerves may be affected ```
54
What do you do in presence of red flags >4 weeks
``` FBC, ESR, LFT Bone profile Myeloma screen inf >50 X-ray CT / MRI Isotope bone scan Bone biopsy ```
55
What do you do first if past history of cancer and current back pain
Isotope bone scan
56
What causes IV disc degeneration What joints
Decreased water content Became narrow Facet joints affected Lumbar and cervical as most mobile
57
RF for degeneration
Smoking
58
How do you Dx
X-ray
59
How do you Rx
IV disc replacement
60
What is and what causes cervical and lumbar spondylosis
OA of joints Degeneration at facet, discs and ligaments Joints become maligned Osteophytes compress nerves Loss of joint space Leads to spinal root compression (radiculopathy)
61
What is the presenting complaint of spondylosis
``` Commonly neck pain Neck stiffness Crepitus Stabbing arm pain / dull Paraesthesia Referred pain may mimic headache ```
62
How do you Dx
MRI
63
How do you treat
Conservative if mild | Surgery
64
What else can develop
Myelopathy if actual cord compressed
65
Where is spinal claudication / stenosis most common
Lumbar region
66
What causes spinal stenosis
``` Congenital Disc herniation Trauma Tumour Facet joint OA / osteophytes ```
67
What are the symptoms of spinal stenosis
Gradual onset Bilateral pain radiating down leg Sensory dysaesthesia Worse walking / exercise Takes several minutes to ease after stopping Worse walking down because spinal canal smaller in extension Pain on extension Relieved flexion Foot drop -ve straight leg rest (compared to prolapse)
68
How do you Dx
Examination often normal | MRI
69
When do you do an MRI
Required to Dx spinal stenosis and exclude other causes If result will change management If suspect infection / fracture / cauda equina / AS / tumour
70
How do you Rx
``` Self management Physically active and exercise NSAID = 1st line PPI if >45 Nerve root injection for acute and severe sciatica Surgical laminectomy Treat as neuropathic pain if sciatica ```
71
How does this differ from vascular claudication
Pain worse walking up hill if vascular
72
What is spondylolisthesis
Vertebral sliding on top of each other irritating bone beneath
73
What are the symptoms of spondylolisthesis
Symptoms vary Pain from compressed nerves +- sciatica Hamstring tight = waddling gait
74
How do you Dx
X-ray | MRI
75
How do you treat
``` Conservative Lifestyle Traction Immobilisation Spinal fusion for persistent pain / trapped nerve ```
76
Complications
Spinal cord / nerve compression
77
What is typical picture of AS and what imaging if suspect fracture
``` Young man Lower back pain Stiff Worse in morning Improves with exercise CT as X-ray a mess ```
78
What is sciatica
Compression of sciatic nerve e.g. from herniation / prolapse
79
What are the symptoms of sciatica
``` Nerve pain in sciatic dermatome Shooting pain Often goes past knee Limited ROM Worse in leg than back Worse with Valsalva / cough / sneezing Sensory Sx Weakness ```
80
How do you treat
Conservative - Physio - Neuropathic medication Surgery referral after 4-6 weeks if failed Rx
81
What is cervical rib
Congenital development of costal process of C7
82
What are the symptoms of cervical rib
``` Asymptomatic Thoracic outlet compression develops - Pain or numb in hand or forearm (ulnar side) - Hand weakness - Muscle wasting - Weak radial pulse +- forearm cyanosis ```
83
How do you Rx
Physio | Rib removal or band division
84
Where is disc prolapse most common
L4 / L5 | PLL as weakest ligament
85
What causes prolapse
Tearing of annuus fibrosis + protrusion Twisting movement Abnormal movement in spondylosis / spondylothesis
86
Who does prolapse tend to affect
Younger
87
What are the symptoms
``` Nerve root pin Altered sensation Motor weakness Reflex change e.g. loss Myelopathy / radiculopathy may develop If central protrusion will cause bilateral signs +Ve leg raise ```
88
If prolapse on cord
UMN signs | Tend not to be painful
89
If pressure below cord / peripheral nerve
LMN | Painful
90
How do you Dx
MRI - will show protrusion + exclude cauda equine | X-ray will show other pathology e.g. osteophyte / loss of joint space
91
How do you Rx
90% settle in 3 months Analgesia - NSAID Physio Nerve root injection
92
When do you refer for MRI
If symptoms persist after 3 months
93
Types of prolapse
Bulge - asymptomatic Protrusion - annulus weakened Extrusion - through annulus Sequestrain - disc maternal free in canal
94
What causes discitis
S.aureus = most common Viral TB Aseptic
95
What are the symptoms
``` Back pain Can get ervical area if IVDU Fever Rigors Sepsis Neuro features of epidural abscess develops ```
96
How do you Dx
Blood culture - Always get unless very ill MRI CT guided biopsy for micro guidance
97
How do you Rx
6-8 weeks of IV Ax | TOE ECHO as usually due to bacteraemia
98
What are complications
Epidural abscess
99
Where does iliopsoas extend from
T12-L5
100
What are primary causes o iliopsoas abscess
Haematogenous spread | S.aureus
101
What are secondary causes
``` Chron's Diverticulitis Colorectal cancer GU cancer UTI Vertebral OM Endocardiits ```
102
What are the symptoms
``` Back / flank pain Pain when psoas is stretched Fever Limp Weight loss ```
103
What are the RF
``` Immunosuppressio HIV Cancer DM IVDA Previous surgery TB ```
104
How do you Dx
CT = gold standard MRI Bloods Full septic screen
105
How do you Rx
Ax Percutaneous drainage Surgery if failure of drainage./ presence of another intra-ado pathology
106
What are the complications
Septicaemia | Multi-organ failure
107
What organism in epidural abscess
S.Aureus = most common Strep E.coli
108
How does epidural abscess develop
Spread from adjacent structure - OM/. discitis Haematogenous Direct from surgery
109
What are the Sx
Back pain Pyrexia Focal neurology Spinal cord compression
110
What are the RF
``` IVDA Immunosuppression DM HIV Chronic renal failure Alcohol Chemo Steroids ```
111
How do you Dx
``` Whole spine MRI to look for skip lesion Bloods HIV / hep B / hep C screen Blood culture ECHO / dental for source ```
112
How do you treat
Surgical emergency Long term IV Ax Urgent surgical decompression
113
When do you do surgery
Large or compressing Not responding Neuro deficit
114
What is costochondritis
Inflammation of ribs Causes non-cardiac chest pain Worse on palpation / movement
115
What indicated referred lumbar pain rather than hip
+Ve femoral stretch

MSK (21 decks)

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