disorders of the spine Flashcards
three most common reason people visit their pcp
skin
joint
back
MC cause of back pain
mechanical
lumbar strain 70%
ddx for back pain
" Degenerative disk disease " Spinal stenosis " Disk herniation " Spondylolisthesis " Compression fracture " Severe deformity (scoliosis, kyphosis
Visceral or Non-Mechanical ddx for back pain
" Neoplasm " Infection (diskitis, osteomyelitis) " Ankylosing spondylitis " Paget's disease " Prostatitis " Dissecting aortic aneurysm " Pancreatitis " Cholecystitis " Gastric ulcer " Nephrolithiasis " PID
most common etiologies of back pain
Muscle strain
Degenerative disk disease
Fracture
etiology of back pain that is self limiting, often associated with heavy lifting or sudden deceleration injuries; pain usually non-radiating
Muscle strain
what does degenerative disk disease look like
develops slowly over time but acute event triggers disk rupture, tear, or herniation resulting discogenic back pain, may also have sciatica
Fxs associated with back pain
most result from compression or flexion injuries and consist of anterior wedging; more severe injury may cause a “burst” fracture with involvement of vertebral body and posterior elements; vertebral chip fracture caused by fall from a height (L5 most common
questions to ask for back pain
how did the pain start was it sudden or gradual where the pattern the intensity the duration what makes it worse or better rest? leg/arm pain, weakness, neumbness, problems walking bowel or bladder problems Hx of pain work or sports history
what specific hx questions might you want to ask a person with back pain
: congenital spine problems, previous episodes of low back pain, previous back injuries
what type of work related qwuestions would you want to ask
any legal action taken related to the pain if this is a work related injury
general medical hx needed for back pain
h. General medical hx, including smoking, drinking, drug use, arthritis, cancer, malabsorption, arthritis, weight loss, fever
PE for back pain
inspection of habitus affect posture gait and active ROM
palpation for back pain
push your thumb on the spinous process and note any tenderness
strength exam for back pain
do a full strength exam and document any abnormal findings
also have them do a straight leg raise
sensation
do a quick sensory exam and document any abnormal findings
reflexes
check patellar and Achilles reflexes and for clonus.
Then check biceps, brachioradialis, and Hoffman’s
hoffman’s test
relax their hand and lift their hand from their middle finger and you flick their middle finger - if positive all the other fingers will move like a jelly fish)
scale for grading strength
- 0/5 - no movement/flaccid
- 1/5 - barest flicker of movement/tone
- 2/5 - can’t overcome force of gravity
can drag across but not up - 3/5 - can overcome gravity, but not any applied resistance
- 4/5 - weaker than normal, but can overcome resistance
( if you can come in and walk but you are
weak )
a. Ex - if you can walk - 5/5 - normal strength
- For strength grading, you may chart with - or + to give a more nuanced pictture
scale for grading reflexes
- 0 - absent
- 1+ - diminished but present
- 2+ - average
- 3+ - brisker but average
- 4+ - very brisk/hyperreflexive
a. Ominous sign
V. Scoliosis
scoliosis workup
hx-usually a-sxs and noticed in school
PE-rib hump with pt bent forward and waist asymmetry and shoulder asymmetry
dx test for scoliosis
Get a 36 inch anterior/posterior XR
Scoliosis is diagnosed as a lateral curve greater than 10 degrees on Cobb angle. It is important to also get a lateral view to check for any associated kyphosis. XRs should be done
annually through puberty until the patient becomes skeletally mature (when the risk of progression is much lower)
tx for scoliosis
i. Regular physical exams by a spine surgeon or neurosurgeon to watch for progression. Bracing may be indicated for aggressively changing curves or curves over 25 degrees
Surgery is indicated for any curve over 50 degrees or rapidly changing curves
Lumbar disk problems causes
This is a common cause of chronic and recurrent low back and leg pain
areas of the spine where we most commonly see disc problems
Most often at L4-L5 or L5-S1, but can involve any level of the lumbar spine
what population do we normally see disc issues in
c. Worse in those who have a history of heavy repetitive lifting, smoking (dries the discs out faster), or driving
what is central stenosis
d. Degeneration of the nucleus pulposus and the annulus fibrosus; the disk may protrude posteriorly, causing central stenosis. This can push on the dura and compress nerves
what is foraminal stenosis
e. The intervertebral space may decrease as the disk degenerates, which can cause foraminal stenosis and may compress one or both of the exiting nerve roots
two components of the intervertebral disc
annulus is the OUTER
inner is the nucleus pulposa
Hx of an individual with suspected disc issues
pain-sudden or insidious w/ or w/o associated even
acute disc herniations generall cause MORE LEG PAIN (i.i nerve root pain) while degeneration gernally causes more back pain
leg pain is dermatomal with paresthesias and tingling may also have weakness in specific muscle group
herniations are usually self-limited >90% of the time while degeneration will worsen
exam for suspected disc disorder
mechanical back pain wiht motion in ddd
may have blunted achilles reflex or patellar reflex
achilles reflex is assoicated with which nerve roots
L5-S1
patellar reflex is assocaited with which spinal roots
L3-4
what is another reason you may not have a good reflex exam in a pt
DM
other specific exam findings of ddd
may have weakness in specific myotome -For example, weak dorsiflexion (tibialis anterior) for L4-5 disk, or weak plantar flexion (gastrocnemius/soleus) for L5-S1 disk (if L5-S1 neuropathy - then they can’t flex their great toe)
what is saddle anesthesia
reduced rectal tone and bowel/bladder incontinence in cases of cauda equina (a surgical emergency)
dx studies of ddd
when would we use MRI
i. XR may show loss of disk space height in degenerative disk disease
MRI is the study of choice for disc herniation
disc herniation is most common at
what would we see on a MRI
L4-L5 OR L5-S1
what would we see on a MRI of disc herniation
, can be central or lateral, may look like a bulge in the disk or may be an extruded disk fragment
degeneration can sometimes be seen as modic changes at the vertebral endplates (inflammation associated with arthritis)
iv. For people who can’t get MRI what is the study of choice for disc herniation
CT MYELOGRAM
Treatment for disc herniation
Approximately 80% of disk herniation pain will resolve within six weeks
During that time, advise your patient to avoid heavy lifting and repetitive bending
NSAIDS, oral prednisone, narcotics, muscle relaxants
Nerve membrane stabilizers for nerve pain: gabapentin, pregabalin
Physical therapy can increase ROM and strengthen core muscles. Acupuncture may help with pain
Corticosteroid epidural injections may provide relief of neurogenic pain (sciatica)
when should you refer to a surgeon
Refer to spine surgeon for new onset or progressive weakness or incapacitating pain beyond 6 weeks (microdiskectomy for disk herniations or lumbar fusion for degenerative disk disease)
when would we need a emergent surgeon referral
vii. If cauda equina is suspected, get a surgical evaluation right away
what are some unique problem with cervical disc
more mobile and therefore more prone to generation but does not bear weight
hx of cervical spine issue
neck pain w or w/o HA
shooting arm pain radiating or tingling down arm
numbness paresthesia in fingers
progressice weakness unilaterally in specific muscles (deltoid triceps ) or loss of grip strength
MAY have probelms with balance walking or muscle spasms in legs
PE for cervical spine pain
look for loss of sensation in a specific dermatome
KNOW THE FINGERS
try to r/o carpal tunnel with tinnels
brachial plecopathy or ulnar neuropathy
an electromyogram may be indicated
Spurling’s test
ii. Positive Spurling’s test for cervical radiculopathy. May also have neurogenic-type pain just medial to scapula
iii. Always watch for signs of spinal cord comp ression as seen in cervical spinal stenosis
what do these look like
myelopathic gait, ankle clonus, hyperreflexia, Hoffman’s sign)
tx for cervical spine issues
i. NSAIDs, oral prednisone, narcotics, muscle relaxants. Gabapentin or pregabalin may be indicated for severe pain
ii. Physical therapy to improve range of motion
iii. Short term use of soft cervical collar
when would we refer to a surgeon for cervical spine issues
iv. Refer to spine surgeon for incapacitating pain, declining motor function, or severe central stenosis
Ankylosing Spondylitis
onset insidious
low back and butt pain associated with morning stiffness and nocturnal back pain unrelieved by rest but improved with exercise
what diagnostic test would we use for AK
elevated ESR presence of histocompatability antigen HLA-B27
Ankylosing Spondylitis is characterized by what back morphology
Loss of lumbar lordosis w/ exaggeration of thoracic kyphosis
what is the pathophys of AS
Inflammation and erosion of the annulus fibrosis at the point of contact w/ the vertebral body are followed by bony growth; this causes bridging of vertebral bodies and eventual reduction of spinal mobility (“bamboo spine”)
inflammation of spine
Spondylitis
refers to general degenerative process of spine (presence of bony spurs, disk degeneration, etc)
Spondylosis
most common where?
what does it look like on xray
i. Weakened or cracked pars articularis. On oblique XR, the “scottie dog” looks like it has a collar
ii. Most common site is L4-5
Spondylolisthesis
= fracture through the pars articularis w/ displacement (Grades 1-4)
pedicles, and superior articular facets gradually slip anteriorly and leave the posterior elements behind. “Scottie dog” will look decapitated - head separate from body on oblique XR. Vertebral bodies will not line up on lateral views. Graded I-4
pain most commonly associated with herniated disc
increased pain with coughing sitting standing strain
which deep tendon reflex is affected in cauda equina syndrome?
Achilles (ankle) reflex.
What critical diagnoses should be considered in patients with syncope and back pain?
Ruptured abdominal aortic aneurysm, aortic dissection, pulmonary embolism and ruptured gastric/duodenal ulcer.
signs of spinal cord compression in pts with neck pain
mylopathic gait
ankel clonus
hyper reflexia
hoffman’s
pt after car accident has 4+ patellar reflex clonus and bilateral hoofman’s
what do you suspect
disc herniation with spinal cord compression
back pain that worsens with walking
what else do you want to ask to confirm spinal stenosis
lumbar stenosis 7.4 times more likely if pain doesn’t occur when sitting
better with bending
pain in both legs
neurogenic claudication
external portion of the spine
arthritis in the lower spine
What is first line therapy for spinal stenosis?
Adequate pain management, physical therapy, exercise, and weight loss.
spinal fxs arise from
may be from trauma
or may be a chronic degenerative process (usually due to loss of bone density as in osteopenia and osteoporosis)
Associated with focal tenderness
c. New compression fractures from osteopenia may be treated with
vertebroplasty or kypoplasty, where cement is squirted into the bone
which type of fxs are suggestive of malignancy
d. Compression fractures above the mid thoracic region are suggestive of malignancy
Traumatic fractures w/o listhesis (i.e., intact pars articularis) or retropulsion of bony fragments can be treated
w/ external bracing (TLSO), or internal bracing (fusion). Otherwise, surgery is indicated
Pt is a 44 yo woman who jumped from a 2-story window in escaping a fire. She landed on her feet and immediately felt excruciating back pain, worse with movement. She has no weakness and no sensory deficits. Her reflexes are intact
found with compression fx of the spine
needs surgert meow
