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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
Q

Lumbar spine - look

A

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

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26
Q

Lumbar spine - feel

A

Vertebral spine - alignment, tenderness, tenderness
Paravertebral muscles - tenderness, spasm
SI joint
ASIS
PSIS
Height of iliac crest

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27
Q

Lumbar spine - move

A

Flexion
Extension
Lateral flexion

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28
Q

Testing flexion at thoracic spine

A

“Please bend over to touch your toes”

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29
Q

Testing extension at thoracic spine

A

“Lean backwards as far as you are able”

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30
Q

Testing lateral flexion at thoracic spine

A

“With your right hand reach down your right leg as far as possible”

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31
Q

Neurological exam - lumbar spine

A

Schober’s test
Sciatic stretch test
Femoral stretch test
Neurology in lower limb - tone, power, reflex, sensation

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32
Q

Spine - feel

A 
Spinour processes - alignment, tenderness, irregularities 
Paraspinal muscles
Trapezius 
SI joint 
ASIS and PSIS
Height of iliac crest
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33
Q

Spine - move

A

Cervical flexion, extension, lateral flexion, rotation
Thoracic rotation
Lumbar flexion, extension, lateral flexion

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34
Q

What is the Schober’s test for

A

Tests that flexion is not coming from hips with rigid spine

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35
Q

Performing Schober’s test

A

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)

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36
Q

Performing sciatic stretch test

A 
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
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37
Q

Performing femoral stretch test

A

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

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38
Q

Testing dermatomes

A

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

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39
Q

Upper limb reflexes

A

Biceps (C5-6)
Brachioradialis (C5-6)
Triceps (C7)

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40
Q

Lower limb reflexes

A

Knee (L3-4)

Ankle (S1)

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41
Q

Non-infl back pain

A 
Mechanical/ low back pain +/- sciatica
OA 
Spinal stenosis
Spondylolisthesis 
Scoliosis 
Vertebral fracture
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42
Q

Infl back pain

A

Infection e.g. disciitis, osteomyelitis, abscess
AxSpA
Malignancy

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43
Q

Other terms for back pain

A

Discogenic pain Degenerative disc disease
Lumbar disc herniation
Secondary to lumbar degenerative disease
Facet joint pain

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44
Q

Other terms for sciatica

A 
Sciatica/ lumbago 
Radicular pain/ radiculopathy 
Pain radiating to the leg
Nerve root compression/ irritation 
Neurogenic claudication 
Spinal stenosis
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45
Q

Epidemiology of MBP

A

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

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46
Q

Principles of back pain assessment

A 
Symptoms 
Assess if nerve root irritation is present 
Nerve root irritation tests 
Document neurological signs
Excl cauda equina syndrome
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47
Q

Clinical features of MBP

A 
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
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48
Q

What % of back pain is caused by MBP

A

90

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49
Q

Prognosis for MBP

A

Good
50% of pts better within a week
90% better within 6 weeks

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50
Q

Recurrence of mechanical pain

A

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

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51
Q

Features of nerve root pain

A

Unilateral leg pain > back pain
Radiation below knee
Numbness and paraesthesia
Nerve irritation signs

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52
Q

Nerve root pain in only one nerve root

A

Motor, sensory or reflex change

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53
Q

Nerve roots usually affected

A

83% of prolapsed intervertebral discs will involve L5 (51%) or S1 (22%) roots
L5 and S1; 10%
L3 or L4: 17% (usually elderly)

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54
Q

+ve sciatic stretch test

A

Pain behind knee down to heel between 30-70+ degrees

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55
Q

Motor signs for L5 pathology

A

Weak dorsiflexion big toe
Weak dorsiflexion lateral 4 toes
Weak eversion

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56
Q

Motor signs for S1 pathology

A

Absent ankle jerk
Weak gluteal contraction *
Weak knee flexion Weakness toe plantar flexion *
* do not occur without absent ankle jerk

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57
Q

Movement affected by L2 pathology

A

Hip flexion/ abduction

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58
Q

Movement affected by L3 pathology

A

Hip adduction

Knee extension

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59
Q

Tendon reflex affected by L3 pathology

A

Knee jerk

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60
Q

Movement affected by L4 pathology

A

Knee extension

Foot inversion/ dorsiflexion

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61
Q

Tendon reflex affected by L4 pathology

A

Knee jerk

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62
Q

Movement affected by L5 pathology

A

Hip extension/ abduction
Knee flexion
Foot/ toe dorsiflexion

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63
Q

Movement affected by S1 pathology

A

Knee flexion
Foot/toe plantar flexion
Foot eversion

64
Q

Tendon reflex affected by S1 pathology

A

Ankle jerk

65
Q

Epidemiology of sciatica

A

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
Q

Modifiable factors associated w/ a 1st onset of sciatica

A

Smoking
Obesity
Occupational factors
General health status

67
Q

Prognosis for nerve root pain

A

50% of pts with root pain are better within 6 weeks – self-limiting

68
Q

NICE recommendations around back pain

A

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
Q

NICE recommendations about treatment for back pain

A

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
Q

Manual therapy for back pain

A

Spinal manipulation
Mobilisation
Soft tissue technologies such as massage

71
Q

Analgesia for back pain

A

Oral NSAIDS and weak opioids (w/or w/out paracetamol)

72
Q

What does NICE say not to recommend

A 
Belts or corsets 
Foot orthotics 
Traction 
Acupuncture 
USS, TENS, interferential therapy 
Paracetamol alone, opioids, antidepressants or anticonvulsants
73
Q

NICE approved interventions

A

Radio-frequency denervation
Epidural/ nerve root injection
Spinal fusion

74
Q

Sacral epidural

A

Needle goes through one of the holes in the sacrum and is injected with combination of local anaesthetic and steroid
Blind injection

75
Q

Nerve root block

A

Radiologist does CT scan and injects around inflamed nerve root

76
Q

Why recommend physical activity for back pain?

A

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
Q

What do we do for the 10% of pts with back pain that aren’t better at 6 weeks

A

Biological assessment
Physchcological assess,mt
Social assessmnet

78
Q

Biological assessment for back pain

A

Nerve root problems
Red flags
Check CRP/ L spine x-ray if relevant

79
Q

Psychological assessment for back pain

A

Unjustified fears?

Depressed?

80
Q

Social assessment for back pain

A

Family relationships

Work problems

81
Q

Risk factors for chronic

A 
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
Q

Red flags for back pain

A 
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
Q

Cauda equina syndrome

A

Large central disc herniation compressing cauda equina (also tumours/ abscesses)

84
Q

Symptoms of cauda equina

A

Bilateral sciatica
Urinary/ faecal incontinence
Saddle anaesthesia
Widespread (>one nerve root) or weakness in legs

85
Q

O/E for cauda equina

A

Rectal examination reveals reduced tone

86
Q

OA of the spine

A

Incl facet OA

Typically pain is most pronounced in morning and then recurs as joint has been stressed w/ exercise/weight-bearing

87
Q

Who does spinal stenosis affect mostly

A

Elderly pt

88
Q

Spinals stenosis characteristics

A

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
Q

Spondylosis

A

Defect in pars intra-articular, usually 5th neural arch
Usually asymptomatic
Can be associated with LBP

90
Q

What is spondylosis related to

A

Sport in teenage years

91
Q

Dx of spondylosis

A

Oblique plain radiographs (MRI if neurological symptoms)

92
Q

Treatment for spondylosis

A

Conservative

93
Q

Spondylolisthesis

A

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
Q

Causes of spondylolisthesis

A

Spondylolysis
Congenital malformation
Facet joint OA

95
Q

Treatment for spondylolisthesis

A

Conservative, rarely spinal fusion

96
Q

Features of AxSpA as a cause of back pain

A

Synovitis
Enthesitis
Ossification of enthesis esp. the spine
HLA B27 association

97
Q

Infections causing back pain

A

Disciitis
Osteomyelitis
Epidural abscess

98
Q

Spread of vertebral osteomyelitis and disciitis

A

Haematogenous

Orig infection may not be identified

99
Q

Clinical features of vertebral osteomyelitis and disciitis

A

Insidious onset of pain
Spinal tenderness
15% have symptoms and signs of nerve root compression
Fever in less than 50%

100
Q

Ix of spinal infection

A 
Infl markers
Blood cultures 
MR
Do whole spine MRI
Other levels involved in up to 10%
101
Q

Why do we not regularly culture spine biopsy

A

Difficult to get into disc

Low yield of 50%

102
Q

Commonest bugs in spinal infection

A

Staph aureus and coagulase -ve staph

103
Q

Referred pain

A

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
Q

IASP definition of referred pain

A

Pain located in an area with cutaneous innervation that differs from that overlying the site of pathology
Based on dermatomes

105
Q

Main regions activated in response to acute nociceptive stimulation

A 
Spinal cord 
Thalamus 
S1 and S2
Insula 
Anterior cingulate cortex 	Prefrontal cortex
106
Q

Pain pathways

A

Noiciceptive info enter spinal cords and follows contralateral ascending pathways – e.g. spinothalamic tract

107
Q

How does spatial info on pain reach S1 cortex

A

Thalamus

108
Q

Where does emotional interpretation about pain occur

A

Via limbic system

109
Q

Where is sensory info about pain processed

A

S1 sensory cortex

110
Q

Which division of the body is related to radicular referred pain

A

Dermatomes

111
Q

Which division of the body is related to myofascial referred pain

A

Myotomes

112
Q

Which division of the body is related to bone/joint referred pain

A

Sclerotomes

113
Q

Which division of the body is related to visceral referred pain

A

Viscerotomes

114
Q

Neuropathic pain

A

Pathological activation in neurones in dorsal root ganglion
Nociceptor terminals not activated
May involve all fibres: A-alpha, A-beta, A-delta, C

115
Q

Features of radicular referred pain

A

Neuropathic pain
Nerve root tension signs
Sensory, motor, reflex abnormality
Dermatomal representation of pan from nerve root infl

116
Q

How does the brain interpret radicular referred pain

A

S1 cortex interprets pain is segmental nerve root input Pain ‘projected’ and referred to dermatome

117
Q

Somatic referred pain

A

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
Q

Somatic muscular referred pain - gluteus minimus

A

Innervate by Sup. Gluteal n.

Pain in L5, S1, S2

119
Q

Somatic muscular referred pain - tibialis anterior

A

Innervated by deep peroneal n

Pain in L4, L5

120
Q

Somatic muscular referred pain - supraspinatus

A

Pain in C5, C6

121
Q

Why do pt’s w/ hip OA get knee x-rays

A

T2, L1 (cutaneous)
L2,3,4 lumbar plexus (hip flexors/ capsule)
L5,S1 sciatic (acetabular)
Hilton’s Law

122
Q

Hilton’s law

A

A nerve supplying a muscle controlling a joint also innervates the joint

123
Q

Why do pts w/ sacroilitis get a lumbar MRI scan

A

Innervation – L4/5, S1/2/3

124
Q

Dorsal Horn convergence

A

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
Q

How is pain localised in the brain

A

According to a somatotopic map on S1 sensory cortex

126
Q

What do spinal segmental levels map to

A

Body surface dermatomes which also corresponds to S1 cortex representation of body surface

127
Q

Red flags for back pain- spinal fracture

A

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
Q

Red flags for back pain - malignancy

A

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
Q

Cancers most likely to metastasise to spine

A 
Breast
Lung
GI
Prostate
Renal
Thyroid
130
Q

Red flags for back pain - infection

A 
Fever 
TB or recent UTI 
Diabetes 
Hx of iv drug use 
HIV infection, use of immunosuppressants or the pt. is immunocompromised
131
Q

Pain management jigsaw

A 
Interventions 
Medication 
Relaxation 
Complimentary therapies 
Psychology 
Neuromodulation 
exercise 
Lifestyle changes/ coping strategies
132
Q

Pt assessment for back pain - subjective

A 
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
Q

Pt assessments for back pain - objective

A

Physical assessment/ spp to individual pt.

134
Q

Exercise/activity and persistent pain

A 
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
Q

Why do psychological factors affect recovery?

A

Affect everyday behaviour and actions

136
Q

Chronic pain and mental health

A

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
Q

Psychosocial assessment for back pain

A

Attitudes – towards the current position
Beliefs – bout the pain
Compensation – is the pt. awaiting payment for an accident/ injury
Diagnosis – iatrogenesis and miscommunication

138
Q

Behavioural assessment for back pain

A

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
Q

What is pain management about

A

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
Q

Medication and back pain

A

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
Q

PMP

A

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
Q

What do we operate on the spine for

A 
Trauma 
Degenerative condns
Infections 
Deformities 
Tumours
143
Q

Triad of epidural access

A

Fever
Back pain
Neurological deficit

144
Q

Degenerative condns of spine

A 
Claudication 
Spinal stenosis 
Disc prolapse
Spondylolisthesis 
Sciatica
145
Q

Reasons for spine re-operation

A 
Sagittal balance problem 
Metal work 
Impingement on nerve roots
Pseudoarthrosis and failure 
Infection
146
Q

Non-surgical treatment for spinal issues

A

Injections
Ablation
Cord stimulation

147
Q

Materials used in spinal surgery

A

Pedicle screws and rods

Disc replacements

148
Q

Evolution of spinal fixation techniques

A

Minimally invasive spine surgery
Endoscopic spine surgery
Computer navigated spine surgery
Robotic spine surgery

149
Q

Co-morbidities for spinal degenerative condns

A

HTN
OS
RhA
DM

150
Q

Convergence- projection theory

A

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
Q

Somatic vs visceral

A

Somatic = skin, muscles + soft tissue, visceral = internal organs

152
Q

Criteria for infl back pain

A

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
Q

Conservative treatment for sciatica

A

Anti - infl
Muscle relaxants
Physiotherapy
Analgesia

Majority of pt’s settle within 6 weeks

154
Q

Investigation if symptoms of sciatica fail to settle after 6 weeks

A

MRI of spine - identify if there is a disc bulge and any possible impingement

155
Q

What can cause vertebral crush fractures

A

Osteoporosis

Metastasis

156
Q

Contraindications of MRI

A

Pacemakers
Aneurysm clips
Ocular metallic foreign body
Claustrophobia

MBBS - Year 1 (93 decks)

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