Back and Neck Disorders - Exam 2 Flashcards
How many cervical, thoracic, lumbar and sacral vertebral bodies do you have?
cervical 7
thoracic 12
lumbar 5
sacrum 5
What is considered an acute onset for neck/back? subacute? chronic?
acute: less than 6 weeks
subacute: 6-12 weeks
chronic: more than 12 weeks
**What are the 10 red flag symptoms for the neck & back exam?
Age < 20 or >50
Duration > 1 month
Pain unresponsive to therapy
Unexplained weight loss, fever
Nocturnal pain or pain at rest
Neurologic symptoms: saddle anesthesia, bowel/bladder incontinence, urine retention
Long-term steroid therapy
History of cancer
Hx of IV drug use, addiction or immunosuppression
Active infection elsewhere or (+) HIV status
**What are the super red flag symptoms for neck/back pain?
Unexplained weight loss and fever
neurologic symptoms: saddle anesthesia, bowel/bladder incontinence
Pain with neurogenic claudication should think _____
lumbar spinal stenosis
What does pain with flexion make you think?
nerve root irritation from a disc herniation
What does pain with extension make you think?
spinal stenosis or spondylolisthesis
What does pain on contralateral side with lateral bending make you think?
muscle spasm
What does pain on ipsilateral side with lateral bending make you think?
facet joint irritation
nerve root impingement
disk herniation
What does pain with rotation make you think?
muscle spasm, facet joint irritation
What should be included in the neuromuscular testing? What levels of the upper and lower extremity?
Muscle strength
DTRs
Sensation
Upper: C5-8
Lower: L4, L5, S1
What muscles are C5? What reflex? What sensation?
What muscles are C6? What reflex? What sensation?
What muscles are C7? What reflex? What sensation?
What muscles are C8? What reflex? What sensation?
What muscles are L4? What reflex? What sensation?
What muscles are L5? What reflex? What sensation?
What muscles are S1? What reflex? What sensation?
**Draw the C5-S4 Nerve root assessment chart
How do you perform the straight leg raise? What is a positive test? What does it indicate?
Passively flex the hip with the knee extended while patient is in supine position
(+) test = worsening radicular pain (not just low back or hamstring pain) on affected side
Indicates lumbar nerve root compression/irritation (herniated disc)
What is a positive crossed straight leg raise? What does it indicate?
(+) test = radicular pain in affected leg when unaffected leg is elevated
Indicates lumbar nerve root compression/irritation (herniated disc)
When is the Trendelenburg test used? What is a positive test? What does it indicate?
Used to assess hip abductor (gluteus medius) strength
(+) test = pelvis drops below neutral on opposite side of stance limb side
Indicates inadequate gluteus medius strength of stance limb
What is the Babinski test? What is a positive test? What does it indicate?
Performed by stroking plantar foot in an upward motion
(+) test = 1st toe extension and fanning of toes 2-4
Indicates long-tract spinal cord lesion
When is the ankle clonus test performed? What is the proper procedure? What is a positive test? What does it indicate?
Perform this test if achilles reflex is abnormal
Performed by quickly placing foot in dorsiflexion
(+) test = involuntary rhythmic beating of foot (clonus)
Indicates long-tract spinal cord lesion
What are the 4 tests that make up Waddell’s test? When is it used?
superficial tenderness
axial loading
distraction testing
regional disturbances
If patient has 3/4 (+) tests, it indicates patient may have a low likelihood of success with injections or surgical intervention
______ (+) if marked pain with light touch over lower lumbar spine
superficial tenderness
______ (+) if increased lumbar spine pain with light downward pressure on the patients head while patient is standing
axial loading
______ (+) if no pain with seated SLR when patient is distracted during exam
distraction testing
______ non-anatomic sensory or motor impairment
regional disturbances
How is the gait assessment best performed? What are the key components?
best if pt is barefoot
Standard gait
Heel-to-toe
Heels only (L4/L5)
Toes only (S1)
What is included in the 3 view cervical spine? 5 view? What does the 5 view cervical spine view provide a clearer view of?
AP, Lateral, Odontoid
AP, Lateral, Odontoid, AP and PA obliques
Provides a clearer view of the intervertebral foramina
In cervical spine xrays, add ______ if lateral does NOT show down to T1
swimmers view
A modified lateral view that shows the C7-T1 junction
_____ is the initial imaging modality for atraumatic patients and ____ for trauma patients
xrays: non-trauma
CT of c-spine for trauma pt
What are the 2 views of the thoracic and lumbar spine? What view provides a view of the articular facets and pars interarticularis? What is the associated sign?
AP and lateral
oblique lumbar spine
“Scottie dog” sign
What are the causes of acute LBP? What are the risk factors?
injury to the paravertebral spinal muscles, the ligaments of the facet joints, or the intervertebral disk
Poor physical fitness
Job dissatisfaction
Smoking
Psychosocial issues
_____ is the MC cause of lost work time and disability in young adults and is the MC strained area of the body
acute LBP
History of repetitive lifting, twisting, fall or operating vibrating equipment
or just normal bending over
What am I?
Where does it often radiate?
acute LBP
Often radiating into the buttocks and posterior thighs (but NOT down the leg)
What makes acute LBP better and worse?
better: Transient improvement with frequent change in position
worse: moving
Difficulty standing upright
Diffuse tenderness in the low back or sacroiliac region
Decreased ROM due to pain
What am I?
What will the PE reveal?
acute LBP
Reflexes, motor, and sensory exam are normal
NO DEFICITS APPRECIATED
When should you order films in acute LBP?
only if Hx of significant trauma, atypical pain, nocturnal pain, night sweats
because films offer little value in acute LBP
What will xrays reveal in acute LBP in a person less than 30? over 30?
Normal findings in patients < 30 yrs of age
> 30 years of age → physiologic evidence of aging may be seen but is not necessarily pathologic such a disc space narrowing and bone spurs
What is the tx for acute LBP?
reassurance and education on expectations for improvement
heat, massage, acupuncture
NSAIDs/APAP
home stretching/strengthening after pain improves
What 3 things should be avoided in acute LBP?
Avoid intense physical activity
Avoid bed rest (no more than 2 days)
Avoid steroids and narcotics
When should you refer to PT in acute LBP?
Refer to PT if no improvement with home therapy plan
What are the 2 referral indications to neurosx in acute LBP?
- Evidence of neurologic dysfunction on exam->
Order MRI and refer to neurospine surgeon - Unable to return to work after 4 wks
What is the prognosis for acute LBP?
Pain often resolves within 1 month
If no improvement after 4-6 wks → order imaging if not previously ordered
What is considered chronic LBP? What is the pain most likely related to?
Defined as low back pain for >12 weeks
Pain is often recurrent and episodic, but may be unremitting
Most often related to degeneration of the intervertebral structures
What are the risk factors for chronic LBP?
Repetitive trauma
Infection
Heredity
Tobacco use
Pain aching +/- radiation into the posterior leg
Worsened by ROM - bending, lifting, stooping or twisting
Improved by lying down
with associated stiffness often reported
What am I?
What will the PE reveal?
What is the highlighted s/s?
chronic LBP
some lumbar and SI tenderness, mildly limited ROM, SLR may be slightly restricted but neuro exam is normal!!!
stiffness is often reported
What imaging should you order in chronic LBP? Why?
lumbar xray
Rule out pathophysiologic processes if concern on H&P: cancer, stenosis, deformity, osteoporosis or infections
What is the tx for chronic LBP?
refer to pain managment for injections
need to address the deconditioned state, depression or anger
home stretching/strengthening or PT
need to educate about the return to activity, goal oriented program!!
______ is an Injury to the paravertebral spinal muscles and/or the ligaments of the facet joints. What is the MC MOI?
cervical strain
whiplash mechanism/flexion-extension injury
diffuse cervical pain that does NOT radiate that is worse with movement
Associated with paraspinal spasms and occipital headaches
What am I?
Where can the pain occur?
cervical strain
Pain can occur anywhere from the base of the skull to the cervicothoracic junction
What are some PE findings for a cervical strain?
Tenderness in the paraspinous muscles, trapezius, SCM muscles, spinous processes, interspinous ligaments
Limited ROM due to pain
Reflexes, motor, and sensory exams are NORMAL
What are the indications to order cervical imaging in a cervical sprain? What views? What must be seen on imaging?
History of trauma, associated neurologic deficit, or if the patient is elderly
AP, lateral and odontoid
must see all SEVEN cervical vertebrae
What is the typical finding on xray for a cervical strain?
Unless underlying disease (i.e. degenerative disk disease) the xrays will be normal for a simple cervical strain
What is the initial tx for a cervical strain?
Soft cervical collar and mild narcotic and/or NSAIDs x 1-2 wks
Muscle relaxants are helpful for patients with muscle spasm
Cervical pillow used at night to promote healthy posture
What is the tx for a cervical strain once the initial care is complete?
Reassurance and education on expectations for improvement
massage therapy
Aerobic activity (walking), stretching and strengthening exercises of the cervical spine should begin as soon as tolerable
What is CI in an acute cervical strain? What is the prognosis for a cervical strain? What if whiplash is present?
Cervical manipulation
Most often full symptom resolution within 4-6 wks
Whiplash may take up to 12 months for full improvement and some pts develop radiculopathy or intractable pain
What is the MOI for a cervical spine fx?
High-energy trauma
extreme ROM injury
axial compression injury
C1 is _____ and C2 is _____. What is considered a Hangman’s fx?
C1= atlas
C2= axis
Bilateral fractures of the pedicles or pars interarticularis of C2
What vertebra is an odontoid fx?
C2
What type of fracture? Stable or unstable?
Type I of C2
unstable
What type of fracture? Stable or unstable?
type II of C2
unstable
What type of fracture? Stable or unstable?
type III of C2
stable and has the best prognosis for healing
_____ is the most missed spinal fx. Why?
cervical spine fx
patients who are obtunded from a head injury, unconscious, and/or intoxicated and do NOT specifically complain of neck pain
What do cervical spine fx with Focal UE numbness or tingling indicate? with Global sensory/motor deficits?
nerve root impingement
spinal cord injury
What should be included in the PE of a cervical spine fx?
Patient should be in a c-collar and on a backboard
assess for swelling and contusion
Palpate for point tenderness over the spinous processes and paraspinal spasm-> looking for a gap or step off between spinous processes
Neuro exam! Assess reflex, motor, and sensory function
including perinanal sensation/reflexes
What does an abnormal perianal sensation or anal reflex indicate?
Abnormal findings indicate lesion of spinal cord at S2-4 or higher
What is the bulbocavernosus reflex?
a reflex elicited by squeezing the clitoris or glans penis and watching for movement of the perineum or anal sphincter
What is spondylolysis? Spondylolisthesis?
Spondylolysis is a fracture (crack or break) in a vertebra (bone in the spine)
Spondylolisthesis is a condition where one vertebra (a bone in the spine) slips forward over the vertebra below it
Spondylolysis
Spondylolisthesis
What is the criteria to rule OUT the need for cervical spine imaging? What must the GCS score be?
NEXUS criteria to rule out!
- No posterior midline cervical-spine tenderness
- No evidence of intoxication
- A normal level of alertness
- No local neurologic deficit
- No painful distracting injuries
Imaging not needed if patient satisfies all 5 criteria, then can remove c-collar
need a GCS score of 15
What is the initial modality of choice for a moderate/high risk c-spine trauma? low/moderate risk?
CT of the C-spine (non-contrasted): moderate- to high-risk
low-moderate risk: Cervical spine series xrays
When is a MRI indicated in a cervical spine fx?
concern for spinal cord or vertebral artery injury
What is the tx for a stable cervical spine fx?
Maintain cervical spine immobilization
+/- IV steroids
Consult ortho/neurosurgery
Stable fx → may consider closed reduction with halo-vest immobilization
control pain
What is the tx for an unstable cervical spine fx?
Maintain cervical spine immobilization
+/- IV steroids
Consult ortho/neurosurgery
Unstable fracture → ORIF
pain control
What is the tx for a cervical spine OCCULT fx who has normal neuro exam and imaging?
Soft cervical collar x 7-10 days
Re-evaluate in 7 days and repeat x-rays if pain persists
If x-rays remain normal add extension-flexion lateral views and MRI
If additional imaging is normal start PT
What is the MOI for a thoracolumbar vertebral fx? What pt type has a higher risk?
high energy trauma: usually MVA or fall from height
or minimal trauma in pts with osteoporosis or malignant bone dz
Moderate-severe back pain following trauma
Neurologic symptoms with nerve root or spinal cord injury
will be tender
What am I?
What do you need to do next?
Thoracolumbar Vertebral Fracture
Assess all DTR, motor, and sensory function of LE and anus. Look at torso for s/s of swelling and ecchymosis
What is the tx for a thoracolumbar vertebral of the isolated transverse process? Does it affect the stability of the spine?
Thoracolumbar corset → symptom relief
oral narcotics for pain
consider IV steroids
Do not affect stability of the spine
What is the tx for a thoracolumbar vertebral stable simple compression fx that is less than 20 degree of wedge? What is the pt education?
Thoracolumbosacral orthosis (TLSO) for 8 to 12 weeks
oral narcotics for pain, consider IV steroids and consult neurosx for potential surgical intervention
Worn during sitting and standing
Avoid twisting, bending, stooping or lifting > 20 lbs
What are the sx options for a thoracolumbar vertebral fx?
Kyphoplasty
Vertebral fusion
Corpectomy (vertebrectomy)
Internal fixation with pedicle screws
_____ is contraction of the neck muscles causing the head to deviate to one side. What are the 3 MC muscles involved?
torticollis
Sternocleidomastoid, trapezius, and posterior cervical muscles
What is congenital muscular torticollis?
Birth trauma or intrauterine malposition causing damage to the SCM muscle
What is acquired torticollis caused by? What is the tx?
Blunt trauma or sleeping in awkward position (MC)
self limiting
What medication SE have been known to cause torticollis?
antipsychotics and antiemetics
What is the tx of torticollis? What if ____ fails?
Remove or treat any underlying etiology
NSAIDs, Benzo’s, or other muscle relaxants
botox injections
botox fails -> Surgical release of SCM, selective denervation, dorsal cord stimulation
_____ is narrowing of the intraspinal/central canal at one or more levels with subsequent compression of the nerve roots
spinal stenosis
What are some common etiologies for spinal stenosis?
Degenerative changes
Space occupying lesions
Traumatic/post-op fibrosis
Skeletal disease: Paget’s, Ankylosing spondylitis, RA
congenital conditions: dwarfism or spina bifida
neurogenic claudication
LE pain is typically radicular and bilateral worse with extension
What am I?
What is the associated timing?
What makes it better or worse?
spinal stenosis
can be insidious or rapid onset
Worsened by spine extension, relieved with spine flexion
______ is discomfort, sensory loss, and weakness in the legs with walking, relieved with sitting, flexing at the waist, or lying down. What dx is it associated with?
neurogenic claudication
spinal stenosis
____ ____ and ____ are usually normal in spinal stenosis but ____ may be diminished
motor, sensory and peripheral pulses are normal
DTRs may be diminished
_____ is often needed to differentiate concomitant prostate/stress incontinence from spinal disease. What do you need to differentiate between when working a pt up for spinal stenosis
GU exam
need to differentiate if it is neurogenic vs vascular claudication
_____ is the imaging of choice to dx spinal stenosis. What if that is unavailable?
MRI
CT with myelography (dye into spinal cord then serial xrays are taken)
What are the first line therapy options for spinal stenosis?
PT, water aerobics, NSAIDs
Epidural steroid injection
What are the indications for sx in spinal stenosis?
Symptoms cause difficulty ambulating or diminished quality of life
Evidence of neurologic deficit, bowel/bladder dysfunction
_____ is a chronic inflammatory disease of the joints of the axial skeleton of unknown etiology characterized by back pain and progressive stiffness of the spine. What is the average age of onset? What gender?
ankylosing spondylitis
Onset: average 15-25 y/o
Male > females
What is the pathophys behind ankylosing sopondylitis?
enthesitis with chronic inflammation, including CD4+ and CD8+ T-lymphocytes and macrophages
What is enthesitis? Commonly seen in what dx?
Enthesitis is inflammation of the entheses, the sites where tendons or ligaments insert into the bone
ankylosing spondylitis
Gradual intermittent onset
Back pain and morning stiffness improving with activity
Cephalad progression
Progressive loss of ROM → fusion of entire spine
Loss of lumbar lordosis and exaggerated thoracic kyphosis
Enthesopathy
peripheral arthritis
What am I?
What other organs are typically involved?
What is the hallmark of the disease?
ankylosing spondylitis
Anterior uveitis (< 25%)
Cardiac disease (3-5%)
Enthesopathy (hallmark)
**What lab finding is associated with ankylosing spondylitis? What does it represent?
HLA-B27
A protein present on WBC that is supposed to help differentiate between “self” and “foreign” cells
When will you start to see xray changes in AK? What 2 xray findings?
SI changes noted 2 years after s/s onset
“The shiny corner sign”
“Bamboo spine”
What will show evidence of AK dz within the first 2 years?
MRI will show evidence of dz within the first 2 years when x-ray is normal
What is the tx for ankylosing spondylitis?
NSAIDs
TNF-alpha antagonists
PT/strength training
refer pt rheumatologist!!!
What is the pathophys behind herniated nucleus pulposus?
A protrusion of the nucleus pulposus through a weakened annulus fibrosus, resulting in compression of the spinal canal
Why is a herniated nucleus pulposus painful? Where are the 2 MC sites?
Pain occurs from direct compression and from chemical irritation from substances within the nucleus pulposus
MC at L4-5 and L5-S1 levels
What are the 2 MOI for herniated nucleus pulposus?
Lifting and twisting injuries
abrupt and severe
Pain, numbness and/or weakness in one or both LE
Shooting or stabbing pain into the buttock and down the leg
What am I?
What makes it worse?
Herniated Nucleus Pulposus
Exacerbated by sitting, walking, standing, coughing, and sneezing and usually unable to find a comfortable position
In a herniated nucleus pulposus, what usually comes first back or leg pain?
leg pain frequently comes before back pain
What will the PE reveal in a herniated nucleus pulposus?
Limited ROM due to pain
(+) SLR
Evaluate DTR’s, motor, and sensory function
What will the xrays reveal in a herniated nucleus pulpsous?
Non-diagnostic
Will reveal age-appropriate changes with no specific findings
What are the MRI indications for a HNP?
Symptoms persist for > 4 weeks
Significant neurologic deficit
Progressive neurologic changes
Intolerable pain
MRI is the best test for HNP
What is the tx for HNP?
NSAIDs
steroids!! medrol dose pack
consider opiates
rest/activity modification
PT once pain free to strengthen core/trunk muscles
What is the pt education with regards to HNP?
Reassurance: Most herniations are self-limiting and improve in 3-4 wks
When should you refer for HNP?
Lack of improvement after 3-4 wks of conservative therapy
Recurrent episodes affecting quality of life
What are the sx options for HNP?
Partial discectomy
Artificial disc replacement
Vertebral Fusion
_____ is a narrowing of the spinal canal compressing the nerve roots of the cauda equina (____ nerve roots)
cauda equina syndrome
L2-L4 nerve roots
What are the common etiologies behind cauda equina syndrome?
Disc herniation/rupture
Spinal stenosis
Spinal trauma/fractures
Neoplasm
Spinal infection/abscess
Idiopathic/Iatrogenic: spinal anesthesia
Cauda equina syndrome is a ______ and _____ can occur if dx and tx are delayed. What is a poorer prognosis?
neurological emergency!!!
Permanent neurologic dysfunction
Patients with bilateral deficits have a poorer prognosis
Saddle and perineal/perianal hypoesthesia or anesthesia
Weak anal sphincter tone
Neurologic s/s unilateral or bilateral
Bowel and bladder changes
Radiculopathy may be unilateral or bilateral
may progress to paralysis
LBP
What am I?
cauda equina syndrome
What imaging should you order in cauda equina syndrome? What if that is NOT available?
Emergent MRI with gadolinium contrast
CT and myelography are alternatives if MRI is CI
What is the tx for cauda equina syndrome? What time frame?
Emergent neurosurgical consult for surgical decompression
Required within 12-24 hours of onset
Treat underlying etiology if indicated
IV methylprednisolone for inflammatory processes
IV antibiotics for infectious etiologies
_____ is a compression of the sciatic nerve as it exits the spine. What is the MC etiology? What are 2 additional ones?
sciatica
herniated disc
bone spur and disc degeneration
_____ is excessive curvature of the thoracic spine. What is the other name for it?
kyphosis
“Dowager’s hump”
What are etiologies for kyphosis?
Vertebral fractures
Degenerative disc disease
Postural changes
Muscle weakness
Genetic predisposition
Changes in the intervertebral ligaments
Is kyphosis always painful?
no!! pt can present because it is painful or for cosmetic reasons
What are some complications of kyphosis?
Impaired pulmonary function
Impaired physical function with increased risk for falling
Increased risk for fractures
Chronic pain
GI symptoms → dysphagia and GERD
Increased mortality
What imaging should you order with kyphosis? What will it show? What is normal?
entire spine series xrays
increased kyphotic cobb angle
normal is 20-40 degrees
What is the tx for kyphosis?
Pain control → NSAIDs and muscle relaxants
Back strengthening exercises
Bracing
Treat any underlying condition as indicated
Refer to ortho or neurospine specialist for evaluation of surgical management
_____ MOA is general CNS depression. What are the CIs?
methocarbamol (Robaxin)
IV form: seizure d/o and renal impairment
______ MOA reduce facilitation of spinal motor neurons. What are the CIs?
tizanidine (Zanaflex)
use with CYP12A inhibitor (cipro, fluvoxamine)
______ MOA reduces motor activity influencing both alpha and gamma motor neurons. What are the CIs?
cyclobenzaprine (Flexeril)
hyperthyroidism, heart failure, arrhythmia, MI recovery phase; ER in elderly
______ is indicated for muscle spasms, TMJ and fibromyalgia are off-label use
cyclobenzaprine (Flexeril)
_____ is a schedule C rx. What is the MOA is unclear/CNS depression. What are the CIs?
carisoprodol (Soma)
unclear - CNS depression
acute intermittent porphyria
_____ MOA is unclear/CNS depression. What are the CIs?
metaxalone (Skelaxin)
renal/hepatic impairment, elderly
