Back and Neck Disorders Flashcards
historical red flags for neck&back exams
- Age < 20 or >50
- Duration > 1 month
- Pain unresponsive to therapy
- Unexplained wt loss, fever
- Nocturnal pain or pain at rest
- Neuro sx - Saddle anesthesia, bowel/bladder incontinence/urine retention
- Long-term steroid therapy
- H/o cancer
- H/o IVDU, addiction or immunosupp
- Active infection elsewhere or (+) HIV
Delayed pain/stiffness
consider what ddx?
Mechanical disorder (muscle strain)
Low back pain radiating down buttock, below the knee
consider what ddx?
Nerve root compression
Back pain at night, unrelieved by rest/supine
consider what ddx?
Malignancy, cauda equina tumor, compression fx
Pain worse with rest, improved with activity
consider what ddx?
Ankylosing spondylitis
Pain worse with activity, improved with rest
consider what ddx?
Degenerative diseases
Writhing pain that is unrelenting
consider what ddx?
Ureteral calculi or dissecting AAA
Pain and fever with hx of IV drug use, immunocompromised, retained hardware or recent back surgery
consider what dxx?
Osteomyelitis, epidural abscess, discitis
Significant or rapidly evolving neuro deficits
consider what ddX?
Cauda equina syndrome, epidural abscess, massive disk herniation
Pain with neurogenic claudication (intermittent leg pain)
consider what ddx?
Lumbar spinal stenosis
ROM for neck and back exam?
- Flexion: Pain → nerve root irritation from disc herniation
- Extension: spinal stenosis or spondylolisthesis
- Lateral bending: contralateral side → muscle spasm; ipsilateral → facet joint irritation, nerve root impingement, disk herniation
- Rotation: muscle spasm, facet joint irritation
nerve roots of UE?
C5-C8
Nerve roots of LE?
L4, L5, S1
- Shoulder abduction, elbow flexion
- Bicep
- Lateral ½ upper arm
which nerve root?
C5
- Elbow flexion, wrist extension
- Brachioradialis
- Lateral ½ lower arm
which nerve root?
C6
C7 nerve root controls what motor, reflex, and sensory?
- Elbow extension, wrist flexion, finger extension
- Tricep
- Middle finger🖕
C8 controls what motor, reflex, and sensory?
- Finger abduction, adduction and flexion
- None
- Medial aspect of lower arm
- Foot dorsiflexion
- Patellar
- Medial foot
which nerve root?
L4
L5 controls what motor, reflex, and sensory?
- Big toe extension
- None
- Midline ventral foot
- Foot eversion
- Achilles
- Lateral aspect of foot
which nerve root?
S1
- Anal sphincter tone
- Bulbocavernosus
- Perianal area
which nerve root?
S2-S4
what is the straight leg raise?
indications?
- Passively flex hip w/ knee extended while supine
- (+) = worsening radicular pain on affected side (not just low back or hamstring pain)
- lumbar nerve root compression/irritation (herniated disc)
- if seated → pt will lean back when hip flexed with knee extended = (+) test
what is the crossed straight leg raise?
indication?
- Also the contralateral SLR
- Performed as in SLR testing, however unaffected leg is passively elevated
- (+) = radicular pain in affected leg when unaffected leg is elevated
- lumbar nerve root compression/irritation (herniated disc)
what is the trendelenburg test?
indication?
- assesses hip abductor (gluteus medius) strength
- stand on one leg; observe level of the pelvis
- (+) = pelvis drops below neutral on opposite side of stance limb side
- inadequate gluteus medius strength of stance limb
what is the babinski test?
indication?
- (+) = 1st toe extension and fanning of toes 2-4
- long-tract spinal cord lesion
- what special testing to do when achilles reflex is abnormal?
- indication?
- Ankle clonus
- Performed by quickly placing foot in dorsiflexion
- (+) = involuntary rhythmic beating of foot (clonus)
- Indicates long-tract spinal cord lesion
What is the Waddell’s test?
- Superficial tenderness = (+) if marked pain with light touch over lower lumbar spine
- Axial loading
- Distraction testing = (+) if no pain with seated SLR when pt is distracted during exam
- Regional Disturbances = non-anatomic sensory or motor impairment
3/4 (+) tests = low likelihood of success with injections or surgical intervention
T/F: gait assessment is preferred if the pt has shoes on
F - best result if dogs are out
4 components of gait assessment
- Standard gait
- Heel-to-toe
- Heels only (L4/L5)
- Toes only (S1)
imaging for cervical spine?
- XR - initial imaging for atraumatic pt
- 3 view: AP, Lateral, Odontoid
3 view + AP and PA obliques (5 view) - CT C-spine - trauma pts
what XR view provides a clearer view of the intervertebral foramina
3 view + AP and PA obliques (5 view)
Add what XR view if lateral doesn’t show down to T1 and will show the C7-T1 junction?
swimmers
lowers the other arm down and rotates both shoulders away = better view
imaging for thoracic spine?
XR - 2 views (AP and lateral)
imaging for lumbar spine?
- XR - 2 views (AP and lateral)
- add oblique: view of articular facets and pars interarticularis; “Scottie dog” sign
- injury to paravertebral spinal muscles, ligaments of facet joints, or intervertebral disk
- MCC lost work time and disability in young adults
- MC strained area of the body
acute low back pain
RF for acute low back pain
- Poor physical fitness
- Job dissatisfaction
- Smoking
- Psychosocial issues
s/s of acute low back pain?
- h/o repetitive lifting, twisting, fall or operating vibrating equipment
- Aching pain in low back - radiates, worsens with movement, transient improvement w/ freq position changing
- Difficulty standing upright
- Diffuse tenderness in the low back or SI region
- Dec ROM
- Reflexes, motor, and sensory exam are normal
indications for XR in acute low back pain?
H/o significant trauma, atypical pain, nocturnal pain, night sweats
normal findings found on XR for acute low back pain?
- Normal findings if < 30 y/o
- > 30 → physiologic evidence of aging (not necessarily pathologic)
- Disc space narrowing
- Bone spurs
mgmt for acute low back pain?
- reassurance and educate
- symptomatic tx - heat, NSAIDs/acetaminophen
- avoid intense physical activity and bed rest (min 2 d)
- slowly return to activity, do stretches
- PT if no improvement
indication to use muscle relaxants for low back pain?
only if evidence of muscle spasm on exam
what meds to avoid in acute low back pain
CS and narcotics
referral indications for acute low back pain?
- Evidence of neuro dysfunction on exam - MRI and refer to neurospine surgeon
- Unable to return to work after 4 wks
prognosis of acute low back pain?
- resolves within 1 month
- no improvement >4-6 wks → imaging if not previously ordered
definition of chronic low back pain?
>12 weeks
recurrent and episodic, but may be unremitting
MCC of chronic low back pain?
degeneration of the intervertebral structures
RF ofr chronic low back pain?
- Repetitive trauma
- Infection
- Heredity
- Tobacco use
s/s chronic low back pain?
- Pain aching +/- radiation into the posterior leg (sciatica) - Worsened by ROM; Improved by lying down
- MC Associated stiffness
- Lumbar and sacroiliac tenderness
- ROM may be mildly limited
- SLR may be slightly restricted
- Reflexes, motor, and sensory exams are normal
w/u for chronic low back pain?
-
Lumbar XR - AP/Lateral
- Age-appropriate changes: anterior osteophytes, reduced height of the intervertebral disks) - R/o pathophysiologic processes if concern on H&P - Cancer, stenosis, deformity, osteoporosis and infectious etiologies
mgmt for chronic low back pain
- referral - Injections, biofeedback, cognitive behavioral programs, spinal cord stimulation, psychotherapy, etc
- Address deconditioned state, depression/anger
- A return-to-activity, goal oriented program
MCC of cervical strain?
whiplash mechanism/flexion-extension injury
- diffuse and nonradicular pain - worsened by movement
- anywhere from base of the skull to cervicothoracic junction
- paraspinal spasms and occipital HA
- Tenderness in paraspinous muscles, trapezius, SCM muscles, spinous processes, interspinous ligaments
- Limited ROM
- Reflexes, motor, and sensory exams are normal
dx?
w/u?
mgmt?
- cervical strain
- +/- cervical XR series (AP, lat, odontoid) - usually normal
- soft cervical collar + mild narcotic/NSAIDs; cervical pillow; massage therapy & cervical traction; +/- muscle relaxant; return to activity as tolerated
indication to order a cervical XR series for cervical strain?
h/o trauma, neuro deficit, old
- All 7 cervical vertebrae must be seen
- XR are nml with a simple cervical strain
CI intervention when there has been an acute injury in cervical strain?
cervical manipulation
prognosis of cervical strain?
- resolution within 4-6 wks
- Whiplash - 12 months possible
- Some develop radiculopathy or intractable pain
3 MOI of cervical spine fx?
- High-energy trauma - MVA, fall from height, diving accident
- Extreme ROM injury - Flexion injury, flexion-rotation injury, extension injury
- Vertical (axial) compression injury
types of cervical spine fx?
- C1 - Atlas
- C2 - Axis
- C3-7: spinous process, pedicle, transverse process, body
ALL patients with cervical trauma should have _____ ruled out!
fracture
what is the hangman’s fx?
C2 - Bilateral fractures of the pedicles or pars interarticularis
what is the odontoid (dens) fx?
C2
s/s of cervical spine fx?
- Severe neck pain +/- radiation after trauma
- Focal UE numbness or tingling (nerve root impingement)
- Global sensory/motor (spinal cord injury)
- In a c-collar and on a backboard
- Point tenderness over spinous processes and paraspinal spasm
- Neuro - Assess reflex, motor, and sensory function
A gap or step-off between spinous processes suggests ?
a ligamentous injury or fractured pars (spondylolisthesis or spondylolysis)
if spinal cord injury is suspected in a cervical spine fx, what specific neuro exams must be performed?
- Perianal sensation, sphincter tone, and the bulbocavernosus reflex or anal reflex
- Abnormal findings = lesion of spinal cord at S2-4 or higher
how to determine who gets C-spine imaging in cervical spine fx?
- NEXUS - must have GCS of 15 to utilize
- Alternative criteria: Canadian C-spine Rules
NEXUS critiera?
Imaging not needed if satisfies all 5 criteria:
- No posterior midline cervical-spine tenderness
- No evidence of intoxication
- A normal level of alertness
- No local neurologic deficit
- No painful distracting injuries
remove c-collar and avoid imaging
imaging options for cervical spine fx
- CT of C-spine
- cervical spine series
- MRI +/- angiography
indications for CT of C-spine in cervical spine fx?
- Initial modality of choice in mod-high-risk traumatized c-spine pts
- abnml XR
what imaging modality is indicated for low-moderate risk trauma patients
cervical spine fx
Cervical spine series (AP, lateral, odontoid)
signs of instability in Cervical spine series (AP, lateral, odontoid)
Cervical Spine Fracture
- Translation of a vertebral body >3.5 mm
- 11 degrees of angulation of adjacent vertebral bodies
indication for MRI +/- angiography for Cervical Spine Fracture?
concern for spinal cord or vertebral artery injury
mgmt for cervical spine fx?
- immobilization
- IV steroids
- consult ortho/neurosurg
- stable fx: closed reduction w/ halo-vest
- unstable: ORIF - pain control
mgmt for occult cervical spine fx
- soft cervical collar
- repeat XR in 1 wk
- add extension-flexion lateral views and MRI if nml
- If additional imaging is nml = PT
MOI of Thoracolumbar Vertebral Fx
High-energy trauma - MVA, Fall from a height
With Thoracolumbar Vertebral Fx, there is minimal trauma in pts with _____ or _______
osteoporosis
malignant bone disease
- in c-collar and on a backboard
- Moderate-severe back pain following a high-energy trauma
- neuro sx w/ nerve root or spinal cord injury (Numbness, tingling, weakness, or bowel and bladder dysfunction)
- torso +/- swelling and ecchymosis - spinal precautions (log-roll)
- Tenderness of area with palpation and/or percussion
- Palpate spinous processes for step off
- Assess all DTR, motor, and sensory function of LE and anus
dx?
w/u?
- Thoracolumbar Vertebral Fx
- Thoracic and lumbar spine series; CT w/o contrast
CT w/o contrast - May be preferred as initial imaging modality in moderate to high-risk injuries
mgmt for thoracolumbar vertebral fx?
- Isolated - Thoracolumbar corset
- Stable, simple compression fx < 20° of wedge - Thoracolumbosacral orthosis (TLSO) x 8-12 wks w/ sitting and standing; Avoid twisting, bending, stooping or lifting > 20 lbs
- Oral narcotic analgesics
- IV steroids
- surgical decompression
T/F: Isolated transverse process fractures do not affect stability of the spine
T
indications for surgery for thoracolumbar vertebral fx?
Burst fractures, flexion-distraction/dislocation, more severe compression injuries
surgical options for thoracolumbar vertebral fx?
- Kyphoplasty
- Vertebral fusion
- Corpectomy (vertebrectomy)
- Internal fixation with pedicle screws
A contraction (spasm) of the neck muscles causing the head to deviate to one side
Torticollis
what muscles are involved in Torticollis
SCM, traps, posterior cervical
causes of torticollis?
which is MC?
- Congenital muscular torticollis (rare): Birth trauma or intrauterine malposition = damage to SCM muscle
-
Acquired
- Blunt trauma or sleeping in awkward position (MC); Self-limiting
- Scarring/dz of cervical vertebrae
- Head/neck soft tissue tumor/infections, enlarged cervical nodes
- Meds - antipsychotics, antiemetics
tx torticollis
- Remove/tx underlying cause
- Conservative - NSAIDs, Benzo’s, muscle relaxants
- Botox
- Surgical release of SCM, selective denervation, dorsal cord stimulation
Narrowing of the intraspinal/central canal at one or more levels with subsequent compression of the nerve roots
Spinal Stenosis
causes of Spinal Stenosis
- Degenerative changes: Disk degeneration, osteophyte
- Space occupying lesions: Lipomas, neoplasms, neural cysts
- Traumatic/post-op fibrosis
- Skeletal dz: Paget’s, Ankylosing spondylitis, RA
- Congenital: Dwarfism. Spina bifida
- insidious or rapid onset
- neurogenic claudication - Discomfort, sensory loss, and weakness in the legs w/ walking, relieved w/ sitting, flexing at waist, or lying down
- LE pain radicular and BL - Worsened by spine extension, relieved w/ spine flexion
- +/- nocturnal pain, bowel bladder changes
- Motor and sensory exam are often normal
- Peripheral pulses are normal
- DTR’s may be diminished
- (+) SLR possible
dx?
Spinal Stenosis
what additional physical exams should be performed for Spinal Stenosis to differentiate concomitant prostate/stress incontinence from spinal disease
- GU
- Must differentiate neurogenic from vascular claudication
w/u for spinal stenosis
- Lumbar series: spondylolisthesis or intervertebral disk narrowing
-
MRI (best choice)
- Alt: CT w/ myelography
mgmt for spinal stenosis
- Conservative, nonsurgical therapy (1st-line) - PT, water aerobics, NSAIDs; Epidural steroid injections
- Surgery - referral to neurospine surgical center
indications for surgery in spinal stenosis
- difficulty ambulating or diminished quality of life
- neuro deficits, bowel/bladder dysfunction
A chronic inflammatory disease of the joints of the axial skeleton of unknown etiology characterized by back pain and progressive stiffness of the spine
Ankylosing Spondylitis
pathophys of Ankylosing Spondylitis
enthesitis w/ chronic inflammation, including CD4+ and CD8+ T-lymphocytes and macrophages
- Gradual intermittent onset
- Back pain and AM stiffness improving w/ activity - Cephalad progression
- Progressive loss of ROM → fusion of entire spine → Loss of lumbar lordosis and exaggerated thoracic kyphosis
- Enthesopathy
- Peripheral arthritis possible
- extra-articular s/s - Anterior uveitis, Cardiac disease, Conduction, valvular dz, Pulmonary fibrosis
Ankylosing Spondylitis
w/u for Ankylosing Spondylitis
- Elevated ESR/CRP
- HLA-B27
- Thoracolumbar spine XR - “Bamboo spine,” “shiny corner sign”
- MRI - shows evidence of dz within first 2 years when XR is normal
- A protein present on WBC that is supposed to help differentiate between “self” and “foreign” cells
- Present in 50-90% of patients with AS
- Not needed for the dx but helps support the dx
HLA-B27
calcifications or heterotopic ossifications inside a spinal ligament or of the annulus fibrosus
what is this called?
Syndesmophytes
mgmt for anklyosing spondylitis
- NSAIDs (1st-line)
- TNF-α antagonists - etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira)
- PT/strength training exercises
- Refer to rheumatologist
A protrusion of nucleus pulposus through a weakened annulus fibrosus = compression of spinal canal
Herniated Nucleus Pulposus
AKA: Herniated Disk, Sciatica
how does a Herniated Nucleus Pulposus cause pain?
from direct compression and from chemical irritation from substances within the nucleus pulposus
Herniated Nucleus Pulposus MC happens at what level of the spine?
L4-5 and L5-S1 levels
MOI of herniated nucleus pulposus
Lifting and twisting injuries
- Onset abrupt and severe
-
Pain, numbness and/or weakness in one or both LE
- Shooting or stabbing pain into buttock and down leg - precedes back pain
- worsen by sitting, walking, standing, coughing, and sneezing
- Unable to find a position of comfort - Limited ROM
- (+) SLR
- Eval DTR, motor, and sensory function
dx?
w/u?
- Herniated Nucleus Pulposus
- XR; MRI
indications for MRI for herniated nucleus polposus
- sx > 4 wks
- Significant neuro deficit
- Progressive neuro changes
- Intolerable pain
mgmt for herniated nucleus pulposus
- NSAIDs
- Corticosteroids - prednisone
- Opiates - only if severe intractable pain & unresponsive
- Rest/activity modification
- Reassurance: MC self-limiting and improve in 3-4 wks
- PT once pain free
- surgery
- Alt: epidural steroid injections, chiro, acupuncture
indications for referral in herniated nucleus pulposus
- Emergent: focal neuro deficit, cauda equina syndrome
- Lack of improvement after 3-4 wks of conservative therapy
- Recurrent episodes affecting quality of life
surgical options for nherniated nucleus pulposus
- Partial discectomy
- Artificial disc replacement
- Vertebral Fusion
A narrowing of the spinal canal compressing the nerve roots of the cauda equina (L2-L4 nerve roots)
Cauda Equina Syndrome
causes of Cauda Equina Syndrome
- Disc herniation/rupture
- Spinal stenosis
- Spinal trauma/fractures
- Neoplasm
- Spinal infection/abscess
- Idiopathic/Iatrogenic - Spinal anesthesia
- Low back pain
- Radiculopathy unilateral/BL
- Bowel and bladder changes
- Bladder: retention, later followed by an overflow incontinence
- Bowel: incontinence, constipation, loss of anal tone and sensation - Saddle + perineal/perianal hypoesthesia or anesthesia
- Weak anal sphincter tone
- Neuro s/s unilateral or BL
- LE motor weakness and sensory deficits - Trouble rising from seated position, foot drop
- Reduced or absent LE reflexes
dx?
w/u?
- Cauda Equina Syndrome
- CBC, CRP, ESR, BUN/Cr; emergent MRI w/ gadolinium contrast
mgmt for cauda equina
-
Emergent neurosurgical consult for surgical decompression
- Required within 12-24 hours of onset - Tx underlying cause - IV methylprednisolone, abx
A compression of the sciatic nerve as it exits the spine
Sciatica
causes of Sciatica and which is MC?
- Herniated disc (MC)
- Bone spur
- Disc degeneration
presentation of sciatica?
w/u?
mgmt?
- Same as HNP
- tx underlying cause
Excessive curvature of thoracic spine
“Dowager’s hump” - Hunchback
The prevalence increases with age
Kyphosis
causes of Kyphosis
- Vertebral fractures
- Degenerative disc disease
- Postural changes
- Muscle weakness
- Genetic predisposition
- Changes in the intervertebral ligaments
complications of Kyphosis
- Impaired pulm function
- Impaired physical function with inc risk for falling
- inc risk for fx
- Chronic pain
- GI sx → dysphagia and GERD
- inc mortality
w/u for kyphosis?
finding?
Entire spine series
Increased kyphotic cobb angle
Nml is 20-40°
mgmt for kyphosis
- NSAIDs and muscle relaxants
- Back strengthening exercises
- Bracing
- tx any underlying cause
- Refer to ortho or neurospine specialist for surgery
indications for methocarbamol (Robaxin)
muscle spasm, tetanus
caution & CI of methocarbamol (Robaxin)
- CI: IV form: seizure d/o and renal impairment
- Caution/DDI: CNS depressant use, elderly
- Preg Cat: C
MOA of methocarbamol
general CNS depression
SE of methocarbamol
drowsiness, dizziness, bradycardia, syncope, N/V, leukopenia, extravasation/tissue damage (IV, IM only)
indication and MOA of tizanidine (Zanaflex)
- Indications: muscle spasm and/or MSK pain, spasticity
- MOA: reduce facilitation of spinal motor neurons
Cautions, CI, DDI of tizanidine (Zanaflex)
- CI: CYP12Ai (cipro, fluvoxamine)
- Caution: hepatic/renal impairment, elderly
- DDI: CYP12A inhibitors, CNS depressants
- Pregnancy/Lactation: C
- Special considerations: taper to d/c
SE of tizanidine
xerostomia, dizziness/drowsiness, weakness/decreased energy
indications and MOA of cyclobenzaprine (Flexeril)
- Indications: muscle spasm; TMJ and fibromyalgia are off-label
- MOA: reduces motor activity influencing both alpha and gamma motor neurons
caution, CI, DDI of cyclobenzaprine (Flexeril)
- CI: hyperthyroidism, HF, arrhythmia, MI recovery phase; ER in elderly
- Caution: acute-closure glaucoma, inc IOP, serotonin inhibitors, liver impairment, seizure disorders
- DDI: MAOI, TCA’S
- Pregnancy/Lactation: B
SE of cyclobenzaprine (Flexeril)
drowsiness/fatigue, dizziness, xerostomia
indication and MOA of carisoprodol (Soma)
- Indications: acute muscle pain
- MOA: unclear - CNS depression
Which skeletal muscle relaxant is Scheduled C-IV and should avoid abrupt withdrawal?
carisoprodol (Soma)
cautions, CI, and DDI of carisoprodol (Soma)
- CI: acute intermittent porphyria
- Caution: seizures, renal/liver impairment, substance abuse, elderly
- DDI: CNS depressants
- Pregnancy/Lactation: C
SE of carisoprodol (Soma)
CNS depression, CYP2C19 Inhibitors - many PPI’s and antiepileptics
indications and MOA of metaxalone (Skelaxin)
- Indications: acute muscle pain
- MOA: unclear - CNS depression
CI, cautions, and DDI of metaxalone (Skelaxin)
- CI: anemia, significant renal/hepatic impairment
- Caution: renal/hepatic impairment, elderly; food inhibits absorption
- DDI: CNS depressants, serotonergic drugs
- Pregnancy/Lactation: C
SE of metaxalone (Skelaxin)
hemolytic anemia, drowsiness, dizziness, N/V
