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MBBS - Year 1 > Clinical Skills - Spinal Disorders > Flashcards

Clinical Skills - Spinal Disorders Flashcards

1
Q

Spinal hx

A 
Pain hx incl stiffness 
Red flags for bone pain 
Long tract sytptoms 
Nerve root irritation 
Cauda equina symptoms
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2
Q

Long tract symptoms atoms

A

Is pathology from within spine itself

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3
Q

Nerve root irritation

A

Compression of peripheral nerve outside spinal cord

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4
Q

Characteristics of nerve root irritation

A

Referred pain
Worse on sneezing and coughing (increases pressure around nerve root)
Positional

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5
Q

How do we divide spine examinations

A

Cervical
Thoracic
Lumbar

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6
Q

Cervical spine examination outline

A

Look - standing
Feel
Move
Neurological exam

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7
Q

Cervical spine - look

A 
Deformity - kyphosis/ scoliosis 
Scars
Swelling 
Muscle wasting - trapezius, sternocleidomastoid
Gait
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8
Q

Kyphosis

A

Question mark sign

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9
Q

Scoliosis

A

S-shape

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10
Q

Cervical spine - feel

A

Spinous process of 7th cervical vertebra
Spinous process of other vertebrae - alignment,m irrregulatitesd, tenderness
Paraspinal muscles - tenderness, spasm
Trapezius - Tenderness, spasm

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11
Q

Cervical spine - move

A

Flexion
Extension
Lateral flexion
Rotation

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12
Q

Testing flexion of cervical spine

A

‘Look down at toes’

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13
Q

Testing extension of cervical spine

A

‘Look up at ceiling’

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14
Q

Testing lateral flexion of cervical spine

A

“Take your left ear to your left shoulder …”

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15
Q

Testing rotation of rotation

A

‘Look over left shoulder, look over right shoulder”

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16
Q

Neurological exam for cervical spine

A

Upper Limb neurology

  • Tone
  • Power
  • Reflexes (triceps, biceps, supinator)
  • Sensation
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17
Q

What does power test for

A

Motor supply

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18
Q

What does sensation test for

A

Sensory supply

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19
Q

Outline of thoracic spine exam

A

Look
Feel
Move

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20
Q

Thoracic spine - look

A

Deformity
Scars
Wasting of paraspinal muscles

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21
Q

Thoracic spine - feel

A

Palpate spine processes (T1-12) - alignment, irregularities, tenderness
Paraspinal muscles - tenderness, spasm

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22
Q

Thoracic spine - move

A

Rotation examined from behind, with patient seated

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23
Q

Examining rotation - thoracic spine

A

“Cross your arms over your chest, now turn your body as far to the right as you can”

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24
Q

Outline of lumbar spine - lumbar spine

A

Look
Feel
Move
Neurological exam

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25
Lumbar spine - look
Look from anteriorly, laterally and posteriorly at skin – colours, scars - Anteriorly: ASIS, muscle bulk, pelvis-leg angle - Laterally: lumbar lordosis, kyphosis, muscle bulk, pelvic tilt - Posteriorly – spinal stenosis, posterior iliac spine, dimples of Venus Ask pt to walk - gait
26
Lumbar spine - feel
Vertebral spine - alignment, tenderness, tenderness Paravertebral muscles - tenderness, spasm SI joint ASIS PSIS Height of iliac crest
27
Lumbar spine - move
Flexion Extension Lateral flexion
28
Testing flexion at thoracic spine
"Please bend over to touch your toes"
29
Testing extension at thoracic spine
"Lean backwards as far as you are able"
30
Testing lateral flexion at thoracic spine
"With your right hand reach down your right leg as far as possible"
31
Neurological exam - lumbar spine
Schober's test Sciatic stretch test Femoral stretch test Neurology in lower limb - tone, power, reflex, sensation
32
Spine - feel
``` Spinour processes - alignment, tenderness, irregularities Paraspinal muscles Trapezius SI joint ASIS and PSIS Height of iliac crest ```
33
Spine - move
Cervical flexion, extension, lateral flexion, rotation Thoracic rotation Lumbar flexion, extension, lateral flexion
34
What is the Schober's test for
Tests that flexion is not coming from hips with rigid spine
35
Performing Schober's test
Identify dimples of Venud Mark skin 5cm above and 10cm below this Place tape measure with 0cm on the bottom mark Note change between 2 higher marks (Should be >5cm)
36
Performing sciatic stretch test
``` Lie pt. supine and examine hip movement Straight leg raise (good side first) Note angle at which referred pain occurs Lower leg by 5-10 degrees Extend/ dorsiflex ankle Confirm the distribution of the pain ```
37
Performing femoral stretch test
Exclude fixed flexion of the hip Lie the pt. prone Slowly flex knee (can extend the hip with the knee in flexion) Confirm the distribution of the pain, usually pain down front of thigh
38
Testing dermatomes
Using cotton wool for light touch – drag cotton ball all along limb to make sure you don’t miss a patch of numbness at least 15-20x Use neurotip injection pen
39
Upper limb reflexes
Biceps (C5-6) Brachioradialis (C5-6) Triceps (C7)
40
Lower limb reflexes
Knee (L3-4) | Ankle (S1)
41
Non-infl back pain
``` Mechanical/ low back pain +/- sciatica OA Spinal stenosis Spondylolisthesis Scoliosis Vertebral fracture ```
42
Infl back pain
Infection e.g. disciitis, osteomyelitis, abscess AxSpA Malignancy
43
Other terms for back pain
Discogenic pain Degenerative disc disease Lumbar disc herniation Secondary to lumbar degenerative disease Facet joint pain
44
Other terms for sciatica
``` Sciatica/ lumbago Radicular pain/ radiculopathy Pain radiating to the leg Nerve root compression/ irritation Neurogenic claudication Spinal stenosis ```
45
Epidemiology of MBP
Prevalence and burden increases with age until around 6th decade Prevalence of back pain is more common in women and increases w/ age, peaking around 7th decade
46
Principles of back pain assessment
``` Symptoms Assess if nerve root irritation is present Nerve root irritation tests Document neurological signs Excl cauda equina syndrome ```
47
Clinical features of MBP
``` Exact cause rarely identifiable: ligaments, muscles, fascia, bursae, facet joints, vertebral discs, SI joints Onset 20-55 yrs. Lumbosacral, buttocks and thighs Pain worse towards end of day Pt is well ```
48
What % of back pain is caused by MBP
90
49
Prognosis for MBP
Good 50% of pts better within a week 90% better within 6 weeks
50
Recurrence of mechanical pain
60% will have a recurrence within 1 year Recurrent attacks tend to settle within 3-5 yrs. Peaks in middle decades and becomes less frequent in later life
51
Features of nerve root pain
Unilateral leg pain > back pain Radiation below knee Numbness and paraesthesia Nerve irritation signs
52
Nerve root pain in only one nerve root
Motor, sensory or reflex change
53
Nerve roots usually affected
83% of prolapsed intervertebral discs will involve L5 (51%) or S1 (22%) roots L5 and S1; 10% L3 or L4: 17% (usually elderly)
54
+ve sciatic stretch test
Pain behind knee down to heel between 30-70+ degrees
55
Motor signs for L5 pathology
Weak dorsiflexion big toe Weak dorsiflexion lateral 4 toes Weak eversion
56
Motor signs for S1 pathology
Absent ankle jerk Weak gluteal contraction * Weak knee flexion Weakness toe plantar flexion * * do not occur without absent ankle jerk
57
Movement affected by L2 pathology
Hip flexion/ abduction
58
Movement affected by L3 pathology
Hip adduction | Knee extension
59
Tendon reflex affected by L3 pathology
Knee jerk
60
Movement affected by L4 pathology
Knee extension | Foot inversion/ dorsiflexion
61
Tendon reflex affected by L4 pathology
Knee jerk
62
Movement affected by L5 pathology
Hip extension/ abduction Knee flexion Foot/ toe dorsiflexion
63
Movement affected by S1 pathology
Knee flexion Foot/toe plantar flexion Foot eversion
64
Tendon reflex affected by S1 pathology
Ankle jerk
65
Epidemiology of sciatica
Sciatica has a lifetime incidence ranging from 13 to 40% | The incidence is related to age – rarely seen before the age of 20, incidence peaks in 5th decade and then declines
66
Modifiable factors associated w/ a 1st onset of sciatica
Smoking Obesity Occupational factors General health status
67
Prognosis for nerve root pain
50% of pts with root pain are better within 6 weeks – self-limiting
68
NICE recommendations around back pain
Examine pt. Do not refer for investigations unless high risk of poor outcome Imaging in specialist setting of care only if result Is likely to change management
69
NICE recommendations about treatment for back pain
Educate to self-manage pain and encourage normal activities Consider a group exercise programme Consider manual therapy Consider psychological approaches Give analgesia Promote and facilitate return to work or normal activities of daily living
70
Manual therapy for back pain
Spinal manipulation Mobilisation Soft tissue technologies such as massage
71
Analgesia for back pain
Oral NSAIDS and weak opioids (w/or w/out paracetamol)
72
What does NICE say not to recommend
``` Belts or corsets Foot orthotics Traction Acupuncture USS, TENS, interferential therapy Paracetamol alone, opioids, antidepressants or anticonvulsants ```
73
NICE approved interventions
Radio-frequency denervation Epidural/ nerve root injection Spinal fusion
74
Sacral epidural
Needle goes through one of the holes in the sacrum and is injected with combination of local anaesthetic and steroid Blind injection
75
Nerve root block
Radiologist does CT scan and injects around inflamed nerve root
76
Why recommend physical activity for back pain?
Rest perpetuates disability May relieve venous congestion and oedema Muscular afferent activity may interfere with pain signal processing Spinal movement may have a similar effect Precise form of exercise seems unimportant
77
What do we do for the 10% of pts with back pain that aren't better at 6 weeks
Biological assessment Physchcological assess,mt Social assessmnet
78
Biological assessment for back pain
Nerve root problems Red flags Check CRP/ L spine x-ray if relevant
79
Psychological assessment for back pain
Unjustified fears? | Depressed?
80
Social assessment for back pain
Family relationships | Work problems
81
Risk factors for chronic
``` Previous hx of back pain Previous time off work/radicular pain Unfit Poor general health Smoking Depression/ anxiety Disproportionate pain behaviour Personal problems Medicolegal proceedings ```
82
Red flags for back pain
``` Malignancy Corticosteroids Pt systematically unwell Wt. loss Widespread neurology Age <20 yrs. or >55yrs Violent trauma Constant, progressive, non-mechanical back pain Thoracic pain IV drug abuse/ HIV infection Persisting severe restriction of lumbar flexion Structural deformity ```
83
Cauda equina syndrome
Large central disc herniation compressing cauda equina (also tumours/ abscesses)
84
Symptoms of cauda equina
Bilateral sciatica Urinary/ faecal incontinence Saddle anaesthesia Widespread (>one nerve root) or weakness in legs
85
O/E for cauda equina
Rectal examination reveals reduced tone
86
OA of the spine
Incl facet OA | Typically pain is most pronounced in morning and then recurs as joint has been stressed w/ exercise/weight-bearing
87
Who does spinal stenosis affect mostly
Elderly pt
88
Spinals stenosis characteristics
LBP radiation to the legs w/ exercise Worst after exertion and standing Relieved by rest over 10 mins or so Relieved by bending forward
89
Spondylosis
Defect in pars intra-articular, usually 5th neural arch Usually asymptomatic Can be associated with LBP
90
What is spondylosis related to
Sport in teenage years
91
Dx of spondylosis
Oblique plain radiographs (MRI if neurological symptoms)
92
Treatment for spondylosis
Conservative
93
Spondylolisthesis
Spontaneous displacement of a vertebral body in relation to the vertebral body directly beneath it Usually displaced in an anterior direction Neurological involvement can occur (less likely w/ OA
94
Causes of spondylolisthesis
Spondylolysis Congenital malformation Facet joint OA
95
Treatment for spondylolisthesis
Conservative, rarely spinal fusion
96
Features of AxSpA as a cause of back pain
Synovitis Enthesitis Ossification of enthesis esp. the spine HLA B27 association
97
Infections causing back pain
Disciitis Osteomyelitis Epidural abscess
98
Spread of vertebral osteomyelitis and disciitis
Haematogenous | Orig infection may not be identified
99
Clinical features of vertebral osteomyelitis and disciitis
Insidious onset of pain Spinal tenderness 15% have symptoms and signs of nerve root compression Fever in less than 50%
100
Ix of spinal infection
``` Infl markers Blood cultures MR Do whole spine MRI Other levels involved in up to 10% ```
101
Why do we not regularly culture spine biopsy
Difficult to get into disc | Low yield of 50%
102
Commonest bugs in spinal infection
Staph aureus and coagulase -ve staph
103
Referred pain
Pain arising or occurring in a region of the body innervated by nerves other than those innervating source of pain (allows us to distinguish two locations)
104
IASP definition of referred pain
Pain located in an area with cutaneous innervation that differs from that overlying the site of pathology Based on dermatomes
105
Main regions activated in response to acute nociceptive stimulation
``` Spinal cord Thalamus S1 and S2 Insula Anterior cingulate cortex Prefrontal cortex ```
106
Pain pathways
Noiciceptive info enter spinal cords and follows contralateral ascending pathways – e.g. spinothalamic tract
107
How does spatial info on pain reach S1 cortex
Thalamus
108
Where does emotional interpretation about pain occur
Via limbic system
109
Where is sensory info about pain processed
S1 sensory cortex
110
Which division of the body is related to radicular referred pain
Dermatomes
111
Which division of the body is related to myofascial referred pain
Myotomes
112
Which division of the body is related to bone/joint referred pain
Sclerotomes
113
Which division of the body is related to visceral referred pain
Viscerotomes
114
Neuropathic pain
Pathological activation in neurones in dorsal root ganglion Nociceptor terminals not activated May involve all fibres: A-alpha, A-beta, A-delta, C
115
Features of radicular referred pain
Neuropathic pain Nerve root tension signs Sensory, motor, reflex abnormality Dermatomal representation of pan from nerve root infl
116
How does the brain interpret radicular referred pain
S1 cortex interprets pain is segmental nerve root input Pain ‘projected’ and referred to dermatome
117
Somatic referred pain
Activation of those nerves distal to dorsal root ganglion and nerve rot may refer to dermatormal segment Convergent input to dorsal horn at segmental level
118
Somatic muscular referred pain - gluteus minimus
Innervate by Sup. Gluteal n. | Pain in L5, S1, S2
119
Somatic muscular referred pain - tibialis anterior
Innervated by deep peroneal n | Pain in L4, L5
120
Somatic muscular referred pain - supraspinatus
Pain in C5, C6
121
Why do pt's w/ hip OA get knee x-rays
T2, L1 (cutaneous) L2,3,4 lumbar plexus (hip flexors/ capsule) L5,S1 sciatic (acetabular) Hilton’s Law
122
Hilton's law
A nerve supplying a muscle controlling a joint also innervates the joint
123
Why do pts w/ sacroilitis get a lumbar MRI scan
Innervation – L4/5, S1/2/3
124
Dorsal Horn convergence
Any afferent input to that spinal segment may refer to the dermatome - Visceral input via visceral ‘SNS’ autonomic fibres - Muscle via nociceptive afferents that run with motor nerve - Joint via nociceptive afferents from joint structures
125
How is pain localised in the brain
According to a somatotopic map on S1 sensory cortex
126
What do spinal segmental levels map to
Body surface dermatomes which also corresponds to S1 cortex representation of body surface
127
Red flags for back pain- spinal fracture
Sudden onset of severe central spinal pain which is relived by lying down People with osteoporosis or those using corticosteroids Structural deformity of the spine (e.g. a step from one vertebra to an adjacent one) may be present There may be point tenderness over a vertebral body
128
Red flags for back pain - malignancy
50+ yrs. or <20yrs Gradual onset of symptoms Severe unremitting pain that remains when pt. is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining e.g. at stool or coughing and thoracic pain Localised spine tenderness No symptomatic improvement after 4-6 weeks of conservative LBP therapy Unexplained wt. loss Past hx of cancer
129
Cancers most likely to metastasise to spine
``` Breast Lung GI Prostate Renal Thyroid ```
130
Red flags for back pain - infection
``` Fever TB or recent UTI Diabetes Hx of iv drug use HIV infection, use of immunosuppressants or the pt. is immunocompromised ```
131
Pain management jigsaw
``` Interventions Medication Relaxation Complimentary therapies Psychology Neuromodulation exercise Lifestyle changes/ coping strategies ```
132
Pt assessment for back pain - subjective
``` HPC, pain patterns, descriptors of pain PMH Previous treatment Medication use Activity patterns A real clear picture of what pain means to the pt. ```
133
Pt assessments for back pain - objective
Physical assessment/ spp to individual pt.
134
Exercise/activity and persistent pain
``` Pt education Goals and education Look at function/ meaningful activities Parameters of exercise – stretching, strength, aerobic Start with an achievable level Gradual increments – (0-20%) ```
135
Why do psychological factors affect recovery?
Affect everyday behaviour and actions
136
Chronic pain and mental health
Pain can affect mental health issues, but mental health can exacerbate pain and associated with poorer outcomes Higher risk of suicide More likely to have lower wellbeing scores
137
Psychosocial assessment for back pain
Attitudes – towards the current position Beliefs – bout the pain Compensation – is the pt. awaiting payment for an accident/ injury Diagnosis – iatrogenesis and miscommunication
138
Behavioural assessment for back pain
Impact on quality of life – daily functioning – changes in their social, occupational and physical activities/ sleep Interactions w/ health service Coping strategies – exacerbating and relieving factors Use of passive coping e.g. alcohol, inactivity
139
What is pain management about
Improve function QoL Helping people to learn how to manage their experience of pain and associates distress in helpful ways NOT about ‘curing pain’ Pts taking more ACTIVE approach and decreasing reliance on healthcare and analgesic medications
140
Medication and back pain
In the absence of red flag pathology, very little evidence for benefit of medication for back pain High risk of long-term dependence w/. short acting opiates Anti- infl may benefit for short term use
141
PMP
Patients offered 10 x 3.5hrs sessions Timetable includes a weekly practical exercise session, a review of personal value-based goals and a psychology session. Qualitative outcomes focused on patient’s own values and goals rather than reduction in measured / VAS pain scores
142
What do we operate on the spine for
``` Trauma Degenerative condns Infections Deformities Tumours ```
143
Triad of epidural access
Fever Back pain Neurological deficit
144
Degenerative condns of spine
``` Claudication Spinal stenosis Disc prolapse Spondylolisthesis Sciatica ```
145
Reasons for spine re-operation
``` Sagittal balance problem Metal work Impingement on nerve roots Pseudoarthrosis and failure Infection ```
146
Non-surgical treatment for spinal issues
Injections Ablation Cord stimulation
147
Materials used in spinal surgery
Pedicle screws and rods | Disc replacements
148
Evolution of spinal fixation techniques
Minimally invasive spine surgery Endoscopic spine surgery Computer navigated spine surgery Robotic spine surgery
149
Co-morbidities for spinal degenerative condns
HTN OS RhA DM
150
Convergence- projection theory
Referred pain is due to parts of the brain being unable to differentiate noxious stimuli from visceral nociceptors vs. somatic nociceptors This is because the somatic and visceral inputs converge at the same spinal level
151
Somatic vs visceral
Somatic = skin, muscles + soft tissue, visceral = internal organs
152
Criteria for infl back pain
Chronic back pain > 3 months with onset before 45 Morning stiffness for > 30 mins Back pain awakens patient in second half of the night Alternating buttock pain 2/4 needed for dx
153
Conservative treatment for sciatica
Anti - infl Muscle relaxants Physiotherapy Analgesia Majority of pt's settle within 6 weeks
154
Investigation if symptoms of sciatica fail to settle after 6 weeks
MRI of spine - identify if there is a disc bulge and any possible impingement
155
What can cause vertebral crush fractures
Osteoporosis | Metastasis
156
Contraindications of MRI
Pacemakers Aneurysm clips Ocular metallic foreign body Claustrophobia

MBBS - Year 1 (93 decks)

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