clinical spine anatomy Flashcards
low back pain
Symptoms: mid back, low back pain, stiffness and loss of function. Neurologic symptoms related to spina nerve root or cord compression (extremity pain, numbness, tingling, weakness, bowel/bladder urgency/incontinence)
Myotome vs dermatome
Myotome: collection of muscle fibers innervated by the motor axons within each segmental nerve root
Dermatome: area of skin innervated by the sensory axons within each segmental nerve root
Herpes zoster/shingles
most common infection of the peripheral nervous sysem. its an acute neuralgia confined to the dermatome distribution of a specific spinal or cranial sensory nerve root
cervical spine sensory testing dermatomes
C3- supraclavicular fossa C4- AC Joint C5- lateral antecubital fossa C6- Thumb C7-Long finger C8 Little finger T1- Medial Antecubital fossa
Lumbar spine exam sensory testing
L3- medial femoral condyle L4- medial malleolus L5- Foot dorsum (3rd MTP) S1- Lateral heel S2- Popliteal foss
Manual muscle testing
5- normal strength (examiner cant ovrcome)
0 no contraction
Causes of muscle weakness
Muscle strain, pain/reflex inhibtion, peripheral nerve injury, nerve root lesion (myotome), upper motor neuron lesion, tendon pathology, avulsion, psychologic overlay
Cervical spine manual muscle testing, myotomes
c5 myotome- tests biceps (elbow flex)
c6- extensor carpi radialis (wrist extensor)
C7- triceps (elbw extensor)
C8- Flexor digitorum profundus (3rd)- distal finger flexor
T1- abductor digiti minimi- little finger abduction
Lumbar spine manual muscle testing, myotomes
L2- iliopsoas- hipflexor L3- quadriceps - knee extensor L4- tibialis anterior- ankle dorsiflexor L5- Extensor Hallicus longus-big toe extensor S1- Gastrocnemus- ankle plantarflexor
Neuromuscular exam reflex testing
0 absent, 4 enhanced and more than normal, 23 norm
Cervical spine reflex testing
C5-biceps reflex
C6- brachioradialis
C7- triceps
Lumbar spine exam reflex
L4- quadriceps (patellar)
L5- Medial hamstring
S1- Gastrocnemius (achilles)
Lhermitte’s sign
Cervical spine special test
Passive anterior cervical flexion elicits electric like sensation down the spine or extremities and implies cervical spinal cord pathology
Spurlings neck compression test
Cervical spine special tests
Reproduction of radicular symptoms with cervical spine extension, rotation and lateral flextion
Implies cervical nerve rooth pathology
Hoffmanns sign
Cervical spine special test
You flick the pt middle finger (passive snapping flextion ofmiddle finger distal phalanx)
Positive test: flexion-adduction of ipsilateral thumb and index finger (UMN lesion)
Lumbar spine special tests
Straight leg raising test (SLR)- pt lies supine while leg raised with the knee extended, examiner stops raising the leg when the pt reports pain
Positive test: leg pain is reproduced at 30-70 d angles
Implies limbar nerver root pathology (L5 or S1)
Femoral nerve stretch test (upper lumbar disc)- pt is placed in prone position while knee is flexed
Positive Test: reproduction of pt’s pain in anterior thigh
Upper motor Neuron Injury
Spinal cord injury, Brain injury / stroke, myelopathy, CNS lesion
Spasticity/hypertonicity, increased reflexes (hyperreflexia), positive pathological reflexes, extensor plantar response
lower motor neuron injury
Anterior horn cell of the sp cd and includes the peripheral nerves
Peripheral nerve entrapment, radiculopathy
Flaccid weakness, loss of reflexes (hyporeflexia), muscle wasting and atrophy
Red flags for malignancy
H/o cancer, unexplained wt loss
Red flags for sp fracture
Major trauma, motor vehicle accident, fall from a height
Minor trauma or strenuous lifting in an older or potentially osteoporotic individual
Prolonged corticosteroid use
Osteoporosis
Advanced age>70
Red flag for infection
Constitutional symptoms (fever and chills), recent bacterial infection (UTI or skin, pneumonia)
Immunosuppression
IV drug abuse
Red flag for cauda equina syndrome
Acute onset urinary incontinency/retention, fecal incontinence, loss of anal sphincter tone
Saddle anesthesia
Global/progressivee weakness in lower limbs
Lumbar strain
Axial low back pain after acute injury, such as 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: RICE, NSAIDs, muscle relaxant pt,
disc herniation
Acute injury/event can be more insidious, limb pain> spine pain (+/- numbness/tingling, weakness)
Worse: Lumbar, sitting, bending, caugh/sneeze. Cervical- ROM
Better: lumbar- standing, walking
Cervical-lying
Myotomal weakness, Dermatomal pain/numbness/tingling, decreased or absent reflex of affected nerve
Spurling or slr positive
Radiculopathy
Posterolateral herniation- most common, posterior longitudinal ligament
Typically: cervical (affects nerve root exiting neural foramen at same level C5 6 HNP–> C6 radiculopathy)
Lumbar: affects nerve root exiting neural foramen below (L3-4 HNP–> L4 radiculopathy)
Cervical spine: C6 C7 most affected
Lumbar spine: L5 S 1 most affected
Pathophysiology: mechanical compression of nerve root, dorsal root ganglion (DRG), dura is mechanically sensative
Biochemical irritation of nerve root: nucleus pulposis contains cytokines, leukotrienes, Cox2, IL 1, TNF a, Can cause apoptosis of DRG cells
Disc herniation treatment
activity modivication- avoid bedrest, pain meds physical therapy, ed[idural steroid injection
Surgery : disecectomy for progressing or profound weakness, refractory symptoms, bowel bladder dysfunction, myelopathy
Ankylosing spondulitis
Early: There is widening of the sacroilliac joint with adjacent sclerosis compatible with sacrollitis , posterior longitudinal ligament sclerosis at L1-L3
Late: there is fusion of both sacroilliac joints compatible with advanced sacrollitis, symmetric syndesmophytes bridging all vertebral bodies resulting in a bamboo spin
There is ossification of the anterior, posterior and interspinous longitudinal ligaments
68
Ankylosing spondylitis
Chronic inflammatory disease, progressive involvement of of sacroiliac and axial skeletal joints, enthesitis and chondritis and osteitis
Males>fem
Systemics: upper lobe interstitial lung fibrosis, irits, CV aortitis etc
Slowly progressive low back pain and stiffness (worse in the morning and with prolonged inactivity, better with exercise)
Reduced lumbar ROM, tender over SI joints, SI joint provocative tests positive, often unremarkable
Elevated CRP, ESR, 90% HLA B27 positive
Treatment: NSAIDS, pt, anti tnf a
Facet joint arthropathy
axial low back pain w/ gradual onset (cervical: worse with cervical extension), lumbar: worse standing/walking, better sitting/lying
Etiology: gradual degenerative changes/osteoarthritis to zygoapophyseal facet joints, facet joints are synovial joints
older pts
Exam shows non specific, pain provoked with active extension, relieved with flexion
Treatment: imaging, NSAIDS, pt,
Lumbar stenosis
slow progressive pain in the back and unilateral or bilateral legs ( worse with standing walking) relieved with lumbar flexion, sitting (dff from PVD- must flext lumbar spine, cycling OK) usually 55yo
Exam: no focal finding, neuro exam normal, check pulses
Etiology: narrowing of the spinal canal (disc, osseous thickening of bone, facet joints, spodylolisthesis), thickening of ligamentum flavum
Treatment: physical therapy, gait aid, nsaids epidural steroids, surgical treatment if intolerable pain and lifestyle restriction despite non operative treatment
compression fracture
majority occur in people with osteoporosis (assoc with prolonged corticosteroid use, in younher pt, consider underlying malignancy such as multiplemyeloma
1/3 asymptomatic
Usualy sudden onset of thoracic or lumbar pain (Can be related to trauma, fall, or heavy exertion, often little or no trauma (sneeze, bending), worse with flexion, movement, better with rest, usually no leg pain
Exam- local tenderness, painful lumbar ROM (especially flexion), normal neuro exam unless nerve affected
Treatment: imaging, malignancy suspected, NSAIDs, acetaminophen , consider bracing 6 weeks, vertebroplasty/kyphoplasty (intractable pain), osteoporosis workup
cauda equina syndrome
back pain, leg pain, numbness, weakness, saddle anesthesia, bowel bladder dysfunction
Etiology- large herniated disc compressing cauda equina most common, exam- reduced or absent reflexes, weakness, decreased rectal tone
Treatment surgery
Cervical myelopathy
Typically grater than 50, subtl and varied presentation which requires a high index of suspicion
Loss of fine motor skills/hand clumsiness
Gait disturbance, BB dysfunction, motor weakness, LE numbness, weakness, pain, symptoms may be attributed to old age
UE and LE with predominantly upper motor neuron findings and weakness below level of cord involvement (hyperreflexia in upper and lower limbs, hoffman’s signs, positive Babinski, ankle clonus)
Lhermitte sin, romberg sign (posterior colum dysfunction , wide base, ataxic, shuffling, slow gait (widening of stance phase, stride length shortening)
Sp cd compression usually gradual progression due to posterior osteophyte formation spinal stenosis, can also occur due to tumor, abcess, hematoma, other cord, compressive lesion
Surgery (laminectomy), typically no role for non operative treatment
