clinical spine anatomy

Question 1

low back pain

Answer 1

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)

Question 2

Myotome vs dermatome

Answer 2

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

Question 3

Herpes zoster/shingles

Answer 3

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

Question 4

cervical spine sensory testing dermatomes

Answer 4

C3- supraclavicular fossa
C4- AC Joint
C5- lateral antecubital fossa
C6- Thumb
C7-Long finger
C8 Little finger
T1- Medial Antecubital fossa

Question 5

Lumbar spine exam sensory testing

Answer 5

L3- medial femoral condyle
L4- medial malleolus
L5- Foot dorsum (3rd MTP)
S1- Lateral heel
S2- Popliteal foss

Question 6

Manual muscle testing

Answer 6

5- normal strength (examiner cant ovrcome)

0 no contraction

Question 7

Causes of muscle weakness

Answer 7

Muscle strain, pain/reflex inhibtion, peripheral nerve injury, nerve root lesion (myotome), upper motor neuron lesion, tendon pathology, avulsion, psychologic overlay

Question 8

Cervical spine manual muscle testing, myotomes

Answer 8

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

Question 9

Lumbar spine manual muscle testing, myotomes

Answer 9

L2- iliopsoas- hipflexor
L3- quadriceps - knee extensor
L4- tibialis anterior- ankle dorsiflexor
L5- Extensor Hallicus longus-big toe extensor
S1- Gastrocnemus- ankle plantarflexor

Question 10

Neuromuscular exam reflex testing

Answer 10

0 absent, 4 enhanced and more than normal, 23 norm

Question 11

Cervical spine reflex testing

Answer 11

C5-biceps reflex
C6- brachioradialis
C7- triceps

Question 12

Lumbar spine exam reflex

Answer 12

L4- quadriceps (patellar)
L5- Medial hamstring
S1- Gastrocnemius (achilles)

Question 13

Lhermitte’s sign

Answer 13

Cervical spine special test
Passive anterior cervical flexion elicits electric like sensation down the spine or extremities and implies cervical spinal cord pathology

Question 14

Spurlings neck compression test

Answer 14

Cervical spine special tests

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

Implies cervical nerve rooth pathology

Question 15

Hoffmanns sign

Answer 15

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)

Question 16

Lumbar spine special tests

Answer 16

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

Question 17

Upper motor Neuron Injury

Answer 17

Spinal cord injury, Brain injury / stroke, myelopathy, CNS lesion

Spasticity/hypertonicity, increased reflexes (hyperreflexia), positive pathological reflexes, extensor plantar response

Question 18

lower motor neuron injury

Answer 18

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

Question 19

Red flags for malignancy

Answer 19

H/o cancer, unexplained wt loss

Question 20

Red flags for sp fracture

Answer 20

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

Question 21

Red flag for infection

Answer 21

Constitutional symptoms (fever and chills), recent bacterial infection (UTI or skin, pneumonia)

Immunosuppression

IV drug abuse

Question 22

Red flag for cauda equina syndrome

Answer 22

Acute onset urinary incontinency/retention, fecal incontinence, loss of anal sphincter tone

Saddle anesthesia
Global/progressivee weakness in lower limbs

Question 23

Lumbar strain

Answer 23

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,

Question 24

disc herniation

Answer 24

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

Question 25

Radiculopathy

Answer 25

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

Question 26

Disc herniation treatment

Answer 26

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

Question 27

Ankylosing spondulitis

Answer 27

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

Question 28

Ankylosing spondylitis

Answer 28

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

Question 29

Facet joint arthropathy

Answer 29

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,

Question 30

Lumbar stenosis

Answer 30

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

Question 31

compression fracture

Answer 31

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

Question 32

cauda equina syndrome

Answer 32

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

Question 33

Cervical myelopathy

Answer 33

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