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MSS > Clinical Anatomy of the Spine > Flashcards

Clinical Anatomy of the Spine Flashcards

1
Q

Back pain

A
  • Low back pain affects 70-90% of people at some time in their lives
  • 2nd most common reason for visits to a primary care physician
  • 2nd most common cause of missed work
  • Most common cause of disability in patients <45 yo and third leading cause of disability for >45 yo
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2
Q

What are some neurologic symptoms related to spinal nerve root(s) or cord compression?

A

Extremity pain

Numbness

Tingling

Weakness

Bowel/bladder urgency/incontinence

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3
Q

What are the components of the musculoskeletal spine examination?

A
  1. Inspection
  2. Palpation
  3. Range of motion
  4. Neuromuscular exam: muscle testing, sensory testing, reflexes
  5. Special tests
  6. Examination of related areas: shoulder (cervical spine) and hip (lumbar spine)
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4
Q

What parts of the spine are most prone to disc herniation? Why?

A

Cervical – increased motion

Lumbar – increased weight bearing

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5
Q

Seperate the gray matter of the spinal cord into the three different sections and their functions.

A

Ventral horn: cell bodies of motor neurons

Lateral horn: cell bodies of autonomic neuons

Dorsal horn: sensory input

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6
Q

Is the ventral rami sensory or motor?

A

Both – has fibers from both sensory and motor components.

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7
Q

A collection of muscle fibers innervated by the motor axons within each segmental nerve (root)

A

Myotome

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8
Q

Area of skin innervated by the sensory axons within each segmental nerve (root)

A

Dermatome

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9
Q

A patient presents with flaccid paralysis of the right arm. No pain, paresthesias or sensory loss noted. Lab reveals polio virus infection. What is the target of the virus?

A

Ventral horn of spinal cord gray matter

Motor system is affected

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10
Q

Which dermatome supplies the thumb?

What about the ulnar side of the hand?

Nipple?

Umbilicus?

A

Thumb: C6

Ulnar hand: C8

Nipple: T4

Umbilicus: T10

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11
Q

Most common infection of the peripheral nervous system. Acute nerualgia confined to the dermatome distribution of a specific spinal or cranial sensory nerve root.

A

Herpes Zoster (shingles)

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12
Q

What are some anterior and posterior landmarks for palpation in the cervial spine exam?

A

Anterior:

  • Hyoid bone: C3
  • Thyroid cartilage: C4-5
  • First cricoid ring: C6
  • Carotid tubercle: C6

Posterior:

  • Occiput
  • Cervical spinous processes: C7 largest
  • Facet joints
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13
Q

Manual muscle testing: rated 5 to 1

A

5: Normal strength – complete ROM against gravity with maximal resistance (examiner cannot overcome)
4: Active movement against gravity and moderate resistance through full ROM (examiner can overcome)
3: Active movement through full range of motion against gravity (no resistance)
2: Active movement through full ROM with gravity eliminated (no resistance)
1: Flicker or trace of contraction, but no joint motion (no palpable muscle action)
0: No contraction palpated (complete paralysis)

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14
Q

What are some causes of muscle weakness?

A
  • Muscle strain
  • Pain/reflex inhibition
  • Peripheral nerve injury
  • Nerve root lesion (myotome)
  • Upper motor neuron lesion
  • Tendon pathology
  • Avulsion
  • Psychologic overlay
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15
Q

How do you test myotome C5?

A

Biceps flexion

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16
Q

How do you test myotome C6?

A

Extensor carpi radialis–extension of wrist

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17
Q

How do you test myotome C7?

A

Triceps – elbow extension

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18
Q

How do you test myotome C8?

A

Flexor digitorum profundus– 3rd distal finger flexion

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19
Q

How do you test myotome T1?

A

Abductor digiti minimi– little finger abduction

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20
Q

How do you test root level L2?

A

Iliopsoas – hip flexion

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21
Q

How do you test root level L3?

A

Quadriceps – Knee extension

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22
Q

How do you test root level L4?

A

Tibialis anterior–ankle dorsiflexion

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23
Q

How do you test root level L5?

A

Extensor hallicus longus–big toe extensor

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24
Q

How do you test root level S1?

A

Gastrocnemius–ankle plantarflexion

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25
Q

What is the scale for reflex testing?

A

0: absent
1: slight or less than normal (trace response, includes response only brought out with reinforcement)
2: lower half of normal range
3: upper half of normal range
4: enhanced and more than normal (including clonus)

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26
Q

What root levels does biceps reflex test? Brachioradialis? Triceps?

A

Biceps: C5

Brachioradialis: C6

Triceps: C7

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27
Q

What root level does the Patellar reflex test? Hamstring? Achilles?

A

**Patellar: **L4

**Hamstring: **L5

**Achilles: **S1

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28
Q

Passive anterior cervical flexion elicits “electric-like” sensation down the spine or extremities.

What does it imply?

A

Lhermitte’s sign

Cervical spinal cord pathology

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29
Q

Reproduction of radicular symptoms with cervical spine extension, rotation, and lateral flexion.

What does it imply?

A

Spurling’s neck compression test

Implies cervical nerve root pathology

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30
Q

Flick the patient’s middle finger.

What is a positive test?

What does it imply?

A

Hoffman’s sign

Positive: flexion-adduction of ipsilateral thumb and index finger

Implies upper motor neuron process affecting cervical spine or brain

31
Q

What test implies lumbar nerve root pathology (L5 or S1)??

A

Straight-leg raising test: patient lies supine while the leg is raised with the knee extended. Examiner stops raising the leg when patient reports pain.

Positive test: leg pain reproduced at 30-70 degree angle

32
Q

Which test implies an upper lumbar nerve root pathology (L2-L4)?

What is a positive test?

A

Femoral nerve stretch test (upper lumbar disc): patient is placed in prone position while the knee is flexed

Positive test: reproduction of patient’s pain in anterior thigh

33
Q

What signs are associated with an upper motor neuron injury?

A
  • Spasticity/hypertonicity
  • Increased reflexes (hyperreflexia)
  • Positive pathological reflexes
  • Extensor plantar response

Think: spinal cord injury, brain injury/stroke, myelopathy, CNS lesion

34
Q

What signs are associated with lower motor neuron injury?

A
  • Flaccid weakness
  • Loss of reflexes (hyporeflexia)
  • Muscle wasting and atrophy

Think: Peripheral nerve entrapment, radiculopathy

35
Q

What are some red flags for malignancy to watch out for?

A
  1. H/o cancer
  2. Unexplained weight loss
  3. Age > 50
36
Q

What are some red flags for a spinal fracture to watch out for?

A
  1. Major trauma (MVA, fall)
  2. Minor trauma or strenuous lifting in an older or potentially osteoporotic individual
  3. Prolonged corticosteroid use
  4. Osteoporosis
  5. Advanced age >70 yrs
37
Q

What are some red flags for infection to watch out for?

A
  1. Constitutional symptoms (fevers, chills)
  2. Recent bacterial infection (UTI, skin, pneumonia)
  3. Immunosuppressin
  4. IV drug abuse
38
Q

Case: 28 yo male with right sided low back pain x3 days after putting his toddler into his car seat. Otherwise healthy. No radiation of pain, numbness/tingling/weakness. Tender and hypertonic lumbar paraspinals, limited (painful) lumbar ROM, normal neuro exam.

A

Lumbar strain

Hx: axial low back pain after acute injury (lifting or twisting), pain worse with movement, better with rest

Etiology: muscle disruption from excessive stretch or tension

Exam: Localized muscle tenderness, reduced ROM, normal neuro exam

Treatment: Relative reset, pain control (NSAIDs, muscle relaxants), physical therapy if >4 wks or recurring, majority self limited

39
Q

Case: 37 yo painter wiht 2 weeks of progressive pain in the neck and right scapular and arm pain. Past 1 wk with shooting pain and numbness down the arm to the hand more severe. Notes numbness downt he arm into the hand and his arm feels weak.

Exam: postitive spurling, weak elbow extension, decreased pain over middle finger

A

Herniated disc

This man would also have absent triceps reflex – LMN injury, hyporeflexia, C7 herniation is triceps

Posterolateral herniation most common

40
Q

Which ligament in vertebral canal forces herniated discs to slip posterolaterally?

A

Posterior longitudinal ligament

41
Q

Which cervical spine levels are most affect by disc herniation? What about lumbar levels?

A

Cervical: C6, C7 most affected

Lumbar: L5, S1 most affected

42
Q

What motor weakness would you expect with a disc herniation that affects C7?

A

Elbow extension; wrist flexion

43
Q

What motor weakness would you expect with a disc herniation that affects L4?

A

Knee extension, ankle dorsiflexion

44
Q

What motor weakness would you expect with a disc herniation that affects C8?

A

Finger flexion and abduction

45
Q

What motor weakness would you expect with a disc herniation that affects L5?

A

Ankle dorsiflexion; great toe extension

46
Q

What different things can cause radiculopathy?

A

Mechanical compression of nerve root:

  • Neural ischemia, increased intraneural pressure
  • Dura is mechanically sensitive
  • Edema of nerve root, DRG

Biochemical irritation of nerve root:

  • Nucleus pulposis contains cytokines, leukotrienes, Cox-2, interleukin-1, TNF-a
  • Can cause apoptosis of DRG cells
47
Q

What does the classical history of a cervical disc herniation look like?

A
  • Numbness, tingling, weakness
  • Worse with motion towards affected side
  • Better lying down
48
Q

What does the classical history of a lumbar disc herniation look like?

A
  • Numbness/tingling/weakness
  • Worse sitting, bending, coughing/sneezing
  • Better standing, walking
49
Q

Is disc herniation an upper or lower motor neuron deficit?

A

Lower – decreased or absent reflex of affected nerve

50
Q

What is the treatment for disc herniation?

A

Activity modification - avoid bedrest

Pain meds: NSAIDs, neuromodulators (gabapentin, pregabalin), possible short course oral prednisone, limited opioids

Physical therapy

Epidural steroid injection – pain control

51
Q

What are some indications for surgical treatment of disc herniation?

A

Progressive (or profound) weakness

Refractory symptoms

Bowel/bladder dysfunction

Myelopathy

52
Q

What percentage of disc herniations improve without surgery?

A

70-85%

53
Q

If there is a disc herniation at C6-C7, what level of spinal nerve is affected?

A

C7 – the spinal nerve associated is always the LOWER vertebrae

54
Q

Case: 34 yo man with chronic back stiffness and pain that has been getting progressively worse over the past few years. Stiffness is worse in the morning and loosens up somewhat by mid-day, but he has difficulty getting up from a chair after prolonged sitting. Feels better when he exercises.

On examination reveals decreased range of back motion without any neurological deficits.

A

Ankylosing spondylitis

Earliest sign on lumbar x-ray would be sacroiliitis – see changes in SI joint, becomes sclerotic and somewaht irregular

Later on you start to see SI joint fusion (this is one of the only conditions that can fuse the SI joints)

Eventually see “Bamboo spine” – symmetric syndesmophytes bridging all vertebral bodies

Also ossification of the anterior, posterior and interspinous longitudinal ligaments

55
Q

What is ankylosing spondylitis?

Does it effect males or females more?

What are some systemic effects?

A

It is a chronic inflammatory disease with progressive invovlement of sacroiliac and axial skeleton joints. Can get enthesitis, as well as chondritis and osteitis.

Affects more males than females in 3:1 ratio

Systemic effects: upper lobe interstitial lung fibrosis, iritis, CV abnormalities (aortitis, aortic insufficiency, cardiomegaly, conduction defects)

56
Q

What are some lab test to run for ankylosing spondylitis?

A

Elevated C-reactive protein, sedimentation rate.

90% HLA-B27 positive (but just because you have this doesn’t mean you WILL get ankylosing spondylitis)

57
Q

What are some treatment options for ankylosing spondylitis?

A
  • NSAIDs: often provide marked relief
  • Physical therapy: emphasis on ROM, spine exercises
  • Anti-TNF-a agents if severe, refractory to NSAIDs
58
Q

What is the difference between spondylolysis and spondylolisthesis?

A

Spondylolysis: can be congenital or acquired, stress fx of lamina with NO slippage of adjacent articulating vertebrae (commonly at L5-S1 site). Radiographic appearance of “Scottie dog” with collar

Spondylolisthesis: is a bilateral defect with anterior displacement of the L5 body and transverse process, the posterior fragment remains in proper alignment over the sacrum (S1). Radiographic appearance of Scottie dog with broken neck.

59
Q

Case: 59 yo female with low back ache for several months limiting standing and walking. No injury or trauma. No pain sitting.

Central, low midline lumbar pain

No lower extremitiy referral, numbness/tingling, weakness

A

Facet joint arthropathy

Hx: axial low back pain, gradual onset

Cervial: worse with cervical extension

Lumbar: worse standing/walking, better sitting/lying

60
Q

What causes facet joint arthropathy?

A

Gradual degenerative changes/osteoarthritis to zygoapophyseal facet joints

More common > 55 yo

61
Q

What is the treatment for facet joint arthropathy?

A

Imaging: NONE or plain lumbar x-rays

NSAIDs, mild analgesics

Physical therapy (flexion bias)

Consider facent joint steroid injections if refractory

62
Q

Case: 77 yo male with 1 year of low back pain.

Pain is intermittent, with pain down both legs to the ankles walking more than 1/4 mile. Pain resolves with sitting, and no pain in bed.

No numbness/tingling or weakness.

Exam normal, except for reduced lumbar ROM (painfree) and mildly decresed achilles reflex bilaterally

A

Most likely lumbar stenosis

History: slowly progressive pain in back – unilateral or bilateral legs

Worse: standing/walking

Relieved with lumbar flexion, sitting (different from peripheral vascular disease – must flex lumbar spine, cycling OK)

In exam: check pulses to R/O PVD

63
Q

What caues lumbar stenosis?

A

Narrowing of the spinal canal by disc, osseous thickening of bone, facet joints, spondylolisthesis, lickening of ligamentum flavum

64
Q

What is the treatment for lumbar stenosis?

A
  • Physical therapy
  • Gait aid – walker facilitates mild flexion (shopping cart sign)
  • NSAIDs, neuromodulators
  • Epidural steroids
  • Surgical txt if intolerable pain and lifestye restriction despite non-operative treatment
  • Lumbar laminectomy can decompress and open up the canal
65
Q

Case: 65 yo healthy female with 2 weeks of severe low back pain after playing vigorously with her grandchildren.

No leg papin or numbness/tingling

Other than her age, no red flags

Exam with local tenderness in upper lumbar region

A

X rays show compression fracture – vertebral body loses height

66
Q

What is the most common underlying condition that predisposes to developing a compression fracture?

A

Osteoporosis

67
Q

What causes compression fractures?

A

Majority in people with osteoporosis

Assoc with prolonged corticosteroid use

In younger patients (<55 yo), consider underlying malignancy such as multiple myeloma

At least 1/3 asymptomatic

68
Q

How do compression fractures usually present?

A

Usually sudden onset of thoracic or lumbar pain

Can be related to trauma, fall or heavy exertion

Often little or no trauma

Worse with flexion, movement

Better with rest

Usually no leg pain

On exam: local tenderness, painful lumbar ROM (especially flexion), normal neuro exam unless nerve affected

69
Q

What is the treatment for compression fracture?

A

Imaging: plain x-rays, consider MRI or CT

If malignancy suspected: get CBC, SPEP (multiple myeloma), alk phos, ESR

NSAIDs, acetaminophen, calcitonin, mild opioids

Consider bracing for 6 wks

Osteoporosis workup if no prior diagnosis

70
Q

Case: 36 yo executive chef with a h/o chronic low back pain. 1 wk ago with increased LBP and new right > left posterior thigh and calf pain after a long flight

4 day sago awoke on return flight wtih escalation of back and leg pain, saddle anesthesia which persists

He reports 1 episode of bowel incontinence, difficulty emptying his bladder, and leg weakness

A

Cauda equina syndrome

Caused by large herniated disc compressing cauda equina (could also be epidural tumor, abscess or hematoma)

On exam: reduced or absent reflexes, weakness, decreased rectal tone

Treament: surgical emergency

71
Q

Case: 74 yo with gradual progression of walking funny

Notes 4 falls in the past month d/t losing balance, difficulty with buttoning his shirt and pants

Exam: hyperreflexia at triceps, patellas, and Achilles, positive Hoffman’s and Babinski, mild weakness of hand intrinsics and diffuse in legs, wide based gait with poor balance

A

Cervical Myelopathy

Typically > 50 yo

Subtle and varied presentation which requires a high index of suspicion

Loss of fine motor skills/hand clumsiness

Gait disturbance

B/B dysfunction

Motor weakness

LE numbness, weakness, pain

Symptoms may be attributed to old age

72
Q

What causes cervical myelopathy?

A

Spinal cord compression, usually gradual progression due to posterior osteophyte formation, spinal stenosis

Can also occur d/t tumor, abscess, hematoma, or other cord compression

73
Q

What is the treatment for cervical myelopathy?

A

Surgical treatment almost always indicated – cervical decompression (laminectomy); May not correct the neuro deficies, but will prevent progression

Typically no role for non-operative treatment unless not a surgical candidate d/t comorbidities

MSS (24 decks)

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