Disorders of the neck and back Flashcards
What are the 3 distinct columns of the spine
Anterior
- Middle
- Posterior
What is the anterior column composed of?
composed of the anterior longitudinal
ligament & the anterior 2/3 of the vertebral bodies, the
annulus fibrosus & the intervertbral disc
What is the middle column composed of?
– composed of posterior longitudinal
ligament & the posterior 1/3 of the vertebral bodies, the
annulus, & intervertebral discs
What is the posterior column composed of?
– all the bony elements formed by the
pedicles, transverse processes, articulating facets,
laminae, & spinous processes
What is the function of the columns of the spine?
Anterior & posterior longitudinal ligaments maintain the structural integrity of the anterior & middle columns
Posterior column is held in alignment by a complex ligamentous system, including the nuchal ligament complex, capsular ligaments & liagamenta flava
If one column is disrupted the other columns may provide sufficient stability to prevent spinal cord injury
If two columns are disrupted the spine may move as 2 separate units, increasing the likelihood of spinal cord injury
Where do the most injuries and wear and tear occur?
C4& C7
What are the 2 function of the cervical and Trap muscles?
- To support & provide movement & alignment for the
head & neck - To protect the spinal cord & spinal nerves when the
spinal column is under mechanical stress
Each spinal nerve arises from 2 roots which are?
- Ventral Root
- contains motor efferent fibers (motor)
- Dorsal Root
- carries primary sensory afferent fibers (sensory)
Spinal nerve then divides into 2 branches which include?
- Dorsal Primary Ramus
- divides & provides innervation to muscular, cutaneous, &
articular branches for the posterior neck structures
- divides & provides innervation to muscular, cutaneous, &
- Ventral Primary Ramus
- supplies the prevertebral & paravertebral muscles & forms
the brachial plexus that innervates the upper extremity
- supplies the prevertebral & paravertebral muscles & forms
Some causes of cervical strain
Paraspinous neck pain with or without radiation to the shoulder
Causes Overexertion Prolonged tension Poor posture Minor trauma Sleeping habits
6 Clinical Features of cervical strain?
Limited neck ROM Deep aching sensation Muscle spasms-May feel a “knot” Headache/dizziness Reproducible pain to palpation No neurological deficits
Imaging for Cervical Strain?
Often normal
A/P Lateral xrays of C Spine
May reveal degenerative changes
Treatment for Cervical Strain
Rest and immobilization
Soft collar, pain meds, muscle relaxers
Use collar no more than 1-2 weeks
Ice (initially) or heat (later)
Exercises/PT to strengthen neck muscles (once pain subsides)
Usually improved 1 week from onset but pain can last 4-6 weeks
Whiplash is caused by?
Acceleration Deceleration injury, usually due to MVA
First there is acute hyperextension
Injury to anterior soft tissue structures of the neck
Ant longitudinal ligament, intervertebral disk, strap muscles, longus colli, SCM
When the vehicle decelerates the head recoils into flexion
Injury to facet capsules, post ligaments, paraspinal muscles
6 Clinical Features of Whiplash?
Variable symptoms Neck pain and stiffness Headache and pain behind the eyes Muscle spasm and decreased ROM Neuro exam normal Imaging usually normal
Treatment for Whiplash
Rest, soft collar, pain meds
Exercises/PT
Cervical Disc Degeneration
Results from wear and tear due to aging and physiologic stress
Water content of the intervertebral disks decreases over time which causes flatter and less elastic disks
Asymptomatic in early disease
Patient that presents with symptoms is usually older and works a labor intensive job, males>females
3 Categories of Clinical Features for Cervical Disc Degeneration
Axial Neck Pain-Slow onset of achiness, radiation, stiffness, headache
Cervical Radiculopathy-Sensory and motor symptoms r/t a specific dermatome and myotome
Cervical Myelopathy-Difficulty with fine motor tasks and LE weakness
Imaging for Cervical Disc Degeneration
AP, Lat, Oblique Xray
MRI-Especially when neurologic symptoms present
CT-Only if MRI not indicated but contrast dye needed
EMG/Nerve Conduction-?useful-Not a sensitive or specific test
Treatment for Cervical Disc Degeneration
NonOperative-Rest, PT, anti inflam meds
Steroid Injections
Surgical-After failing 3 mos of above tx
Type of surgery depends on location and pathology
Surgical complications can be devastating
Cervical Disc Herniation is what?
Displacement of part of the intervertebral disk material into the spinal cord or nerve roots of the cervical spine
The annulus fibrosis is disrupted a portion of the nucleus pulposus protrudes beyond the normal border
Acute/ Chronic Cervical Disc Herniation?
Most common in 4th decade of life, men>women
Acute=Fall or MVA
Chronic=Older patient
Smoking is a risk factor
5 Clinical Features for Cervical Disc Herniation?
Sharp, burning, electric shock like pain
Numbness/Tingling
Weakness
Radiating pain-Shoulder, arm, elbow, fingertips
Difficulty with gait and balance-central herniation w/ cord compression
Imaging for Cervical Disc Herniation?
MRI is the study of choice
EMG/Nerve Conduction
Help to differentiate cervical vs peripheral nerve entrapment
Treatment for Cervical Disc Herniation?
Non Surgical-PT, Medications, Injections
Surgical-1st line with central spinal cord compression from acute injury
Direct decompression of spinal cord
Where are most fatal cervical Fx’s located?
upper cervical levels C1-C2
Where are the most common cervical Fx’s?
C2 or C6/C7
What are Burst Fractures?
involve disruption of both the anterior
& posterior arches that may allow progressive
displacement of the lateral masses of the atlas leading
to vascular & neurologic compromise
Vertical axial loading of the spine can cause two types of fractures of the atlas known as Jefferson Fractures
- Posterior Arch Fractures – more common & typically
heal well with bracing - Burst Fractures
Patients with Jefferson fx’s have neck pain & restricted ROM, but usually normal neurological exam
Open mouth odontoid view xray establishes dx
Fx is suggested by an increased periodontoid space & bilateral symmetric overhang of the lateral masses in relation to the axis (C2)
Odontoid Fracture is what?
direct head impact can fx the odontoid (dens) & may occur at the tip or the base
- avulsion fx at the tip are less common but more stable
- fx at the base has higher rate of non-union w/o surgery
Hangman’s Fracture is what?
fx of the pedicle of the axis resulting from
a hyperextension injury (MVA, diving injuries, headlong
Falls)
- marked displacement of C2 on C3 can be lethal
- if they survive the injury minimal or no spinal cord injury
may result
- present with neck pain & no neuro sx or signs
- treated with immobilization & halo vest
- surgical fusion is indicated if there is non-union or disruption
of the C2-3 disc
What are the 2 Axis C2 Fractures?
Hangmans
Odontoid
What are compression fractures?
Caused by axial loading with or without cervical flexion or extension
May present only with neck pain & spasm in mild Type I & II fractures
In severe fractures Types III – V may present with respiratory arrest & quadriplegia
Most are identified by plain xray & classified by CT
Type 1 Compression Fracture
simple wedge compression fx
Stable fractures that heal well with conservative management of 8-10 weeks in a semi-rigid cervical collar (Philadelphia Collar)
Type 2 Compression Fracture
“teardrop” or isolated anterior-inferior vertebral body compression fractures with intact posterior elements
Occurs when abrupt neck extension causes the anterior longitudinal ligament to pull the anterior-inferior corner away from the remainder of the vertebral body
Conservative Treatment like type 1
Type 3 Compression Fracture
comminuted burst vertebral body fractures. The posterior element remains intact, but bony fragments may be displaced in the into the spinal medullary canal resulting in serious neurological injury
Should be evaluated by CT
Surgical stabilization is needed to prevent late movement of the fragments
Type 4 &5 Compression Fracture
complex vertebral fractures involving the posterior elements
Unstable fractures with poor prognosis & often result in quadriplegia
What is kyphosis and what are the 4 different types?
Curvature of the spine in which the convexity is directed posteriorly
Otherwise known as “hunchback”
Caused by disorders of the discs & vertebral bodies
Different Types
Senile Kyphosis
Postural Kyphosis
Scheuermann’s Kyphosis
Congenital kyphosisWhat is senile kyphosis?
How is it treated?
Multiple areas of disc degeneration at the thoracic level
Xray shows thinning of discs and osteoporosis with mild wedging deformities
Common in elderly
May be symptomatic
Treatment
Maintain good posture
Exercises to strengthen back and abdominal muscles
Light spinal brace may be helpful
What is postural kyphosis?
What are the causes?
What are S/S
What do you do to treat it?
Most common
Girls > Boys
Typically first noticed during adolescence
Caused by poor posture & weakening of the back muscles & ligaments
Slow to develop, but does not continue to become progressively worse
Have symptoms of upper back pain & muscle fatigue
Does not lead to severe kyphosis with a risk of neurologic, cardiac or pulmonary problems
Treatment is stretching & strengthening of muscles
When is Scheuermann’s Kyphosis first noticed?
What is the cause?
First noticed during adolescence
Results from structural deformity of the vertebrae
Requires xray to show wedge of at least 5 degrees at the front of at least three neighboring vertebral bodies
Reason for this is not well understood
3 Treatments for Scheuermann’s Kyphosis?
Bracing for one to two years for those who have not reached full height, along with muscle strengthening & hamstring stretching to relieve the pain
Surgery is rare & only indicated for patients with a curve of 70 degrees or greater, severe pain, or neurological compromise
The discs are removed & a fusion is performed with an anterior approach & then a posterior approach is done to place rods along the spine to hold the fusion in place
What is congenital kyphosis?
Least common
Caused by an abnormal development of the vertebrae prior to birth
Can lead to several of the vertebrae fusing due to failure of formation or failure of segmentation on the anterior portion of the vertebral bodies or discs
Type 1 Congenital Kyphosis
Failure of Formation
- failure of formation of a portion of one or more vertebral bodies
- usually visible at birth as a lump or bump in the infants
spine
- worsens with growth
Type 2 Congenital Kyphosis
Failure of Segmentation
- two or more vertebrae fail to separate & form normal discs &
rectangular bones
- more often likely to be diagnosed later after the child is walking
What is the treatments for congenital kyphosis?
Non-surgical treatment is mostly observation with periodic xray to measure the progression of the curve
Bracing is not indicated as it has been proven to be of no benefit
Curves > 45 degrees or those associated with neurological weakness are treated surgically
Early surgical intervention usually has the best results
What is Scoliosis
Lateral curvature of the spine in an upright position
There is also a rotational deformity which may increase the normal kyphosis and lordosis of the spine
What can Scoliosis be classified as?
Structural-Fixed and non flexible and do not correct with side bending
May be congenital cause
Non Structural-Flexible and corrects with side bending
Seen as a compensatory mechanism due to irregular leg length, local irritation or inflammation
Tends to disappear when the offending disorder is treated
What is idiopathic Scoliosis?
Represents 90% of all scoliosis
Appears to be hereditary but true cause is unknown
Appears clinically between 10-13yo
More common in females
Curve must be greater than 10 degrees
Usually asymptomatic (c/o pain think tumor)
Diagnosed on routine physical exam
What is the treatment for scoliosis?
Most important aspect is early detection
Failure to dx & treat problem early may result in progressive deformity, cardiopulmonary compromise, & disability
Frequent observation & measurement of the curve in younger patients usually every 4-6 months
Curves > 20-25 degrees may need bracing & exercise
Curves > 45 degrees cannot be effectively braced
Curves 45-50 degrees or greater may need surgery to correct the curve & fuse the spine
Clinical Features of Lower Back Pain
Dull, diffuse, deep seated pain in LS region
May or may not radiate to buttocks and hips
Pain worsened by bending and relieved by inactivity
Palpation may reveal paraspinous tenderness or knots
Muscle spasm
Normal neuro exam and normal straight leg raise
Imaging for Lower Back Pain?
May be normal or may show degenerative changes
50yo+ pt image to r/o cancer mets
<20yo image to r/o congenital anomalies
Treatment for Low Back Pain?
Rest and pain meds
Exercise/PT
Educate on proper body mechanics
Relapse is common
Epidemiology and Etiology for Low Back Pain?
Discomfort, tension, stiffness below the costal margin and above the inferior gluteal folds
Second most common complaint to PCP
Lifetime prevalence of 60-90%
Leading cause of disability in the US for adults<45yo
85% of back pain has no identifiable cause and 1/3 will develop chronic back pain
Lumbar Strain
Acute muscular or ligament injury
Incomplete muscle tears or ligament sprains occur and lead to pain over the affected area
Simple acute injury
Responds well to brief rest and tx of symptoms
“Waste Basket” Diagnosis
Exact dx of low back pain can be difficult
Symptom overlap with muscle strain, ligament strain, mild early disk herniation/degeneration
Relevance of imaging difficult to establish
4 Risk Factors for lumbar strain
Obesity
Smoking
Ergonomics
High Heeled Shoes
4 Clinical Features for lumbar strain
Localized pain
Decreased ROM
Negative Straight Leg Raise
No neuro deficits
Treatment for Lumbar Strain?
Short period of rest (1-2days) Early return to normal activities is important Pain meds Exercise Proper ergonomics Weight Loss and Smoking Cessation
Lumbar spinal stenosis
Narrowing of any part of the lumbar spine
Spinal canal, nerve root canal, and intervertebral formina
Can occur at single or multiple spinal levels
Compression of nerve roots is common
Causes
Acquired (most common) or congenital
Acquired causes include degenerative dz, trauma, and spine surgery
Clinical Features for spinal lumbar stenosis?
May be asymptomatic
Neurogenic claudication is the classic symptom
Back/Buttock/Leg pain induced with walking or standing and relieved by sitting
Symptoms in legs usually bilateral
Can walk farther leaning over a shopping cart
Flexed position=Pain relief
Treatment for Lumbar spinal stenosis
**MRI is gold standard for dx
NSAIDS
Exercise
Tx acute episodes of pain
Surgery when medical tx fails
May need second surgery a few years later
Insufficient evidence to support steroid injections
Lumbar disc herniation?
Tears in the annulus fibrosis cause a portion of the nucleus pulposus to extrude through the defect
The resulting mechanical pressure exerted on the nerve roots as well as irritation from direct contact from the NP and the nerves leads to lumbar radiculopathy
Causes of Lumbar disc herniation?
Caused by trauma or degenerative changes or both
L4-5 and L5-S1 are the most commonly herniated disks of the lumbar spine
Clinical Features of Lumbar disc herniation?
Most common presentation is stabbing low back pain with radiating pain, numbness, and tingling into the buttock and down one leg
Pt visibly uncomfortable, prefers to stand with affected knee stretched
Imaging for Lumbar Disc Herniation?
MRI is study of choice
CT can be used if MRI contraindicated
Treatment of Lumbar Disc Herniation?
Non Surgical-PT, meds, injections
Most pts will respond to a non surgical approach
6-12 weeks before considering surgery
Surgical-Laminectomy or discectomy
Ankylosing Spondylitis
Chronic inflammatory condition of the joints of the axial skeleton, considered an autoimmune arthritis
Manifests as morning stiffness in the low back with progressive loss of spinal movement
10 times more common in men and can be familial
Avg age of onset 15-30yo
Clinical Features of Ankylosing Spondylitis
Bilateral sacroiliac tenderness
Limited motion of lumbar spine
Loss of chest expanasion to <2.5cm due to costosternal involvement
Pain usually located low in the buttocks and thigh region
Imaging Findings for Ankylosing Spondylitis?
Xray or MRI(detecting early AS)
Early findings usually bilateral sacroiliitis
Squaring of the anterior vertebral bodies
May be complete fusion of the SI and hip joints
Bamboo Spine Appearance
3 Ddx for Ankylosing Spondylitis?
Psoriatic Arthritis
Later involvement of SI joints, +skin lesions, no pulmonary dz
Reiter’s Syndrome
Later involvement of SI joints, +urethritis, no pulmonary dz
Rheumatoid Arthritis
Treatment for Ankylosing Spondylitis?
Medications-NSAIDS, DMARDs, TNF Blockers Exercise Postural Training Surgery (Severe AS) Refer to Rheumatology and PT
Cauda Equina Syndrome?
Injury of multiple lumbosacral nerve roots within the spinal canal distal to where the cord ends at L1-2. Does not affect the spinal cord itself
Signs/ Symptoms of Cauda Equina Syndrome?
Low back pain
Weakness and areflexia of on legs
Loss of bladder/bowel function
Saddle anesthesia
Causes of Cauda Equina Syndrome?
Ruptured LS intervertebral disk
LS Spine fracture
Hematoma in the spinal canal (s/p LP)
Tumor or mass lesion
Treatment of Cauda Equina Syndrome?
Diagnosis by MRI
Treatment
Surgical decompression
Radiotherapy for tumors
