L-spine 2

Question 1

What is lumbar spinal stenosis

Answer 1

disc degeneration in aging population
arthritic changes to lumbar vertebrae and facet joints
thickening of ligamentum flavum
narrowing of the spinal canal and nerve root canals
compression of neural structures

Question 2

Osteoarthritic spine shows

Answer 2

osteophytes

narrowed disc spaces

Question 3

How do movements affect pain in lumbar stenosis

Answer 3

Worse with lumbar extension

Better with leaning forward (makes disc spaces larger)

Question 4

Clinical manifestations of lumbar stenosis are

Answer 4

50+ y/o 
insidious onset 
Low back and leg pain (morning stiffness in low back, radiates to LE) 
Claudication with walking 
Shopping cart sign 
\+/- numbness and tingling

Question 5

What is NOT common with lumbar stenosis

Answer 5

weakness!

although they can have some foot drop with prolonged walking

Question 6

What does a neuro exam in lumbar stenosis typically look like

Answer 6

Normal!
Few will have sensory changes
motor deficits are usually mild, and hard to differentiate between age related changes

Question 7

Explain Vascular claudication

Answer 7

cramping, tightness 
relief w/ standing 
Bruits (low blood supply) 
Absent pulses 
Shiny skin 
Hair loss

Question 8

Explain neurogenic claudication

Answer 8

numbness, aching, sharp 
relief w/ siting flexed 
occasional atrophy and weakness 
*Back pain 
Limited ROM to spine

Question 9

What imaging diagnoses lumbar stenosis

Answer 9

Radiographs (XR)
MRI
-narrowed disc spaces, narrowing of spinal canal

Question 10

What is Spondylolithesis

Answer 10

Forward movement of one vertebrae on top of another

Can occur commonly during growth spurt

Question 11

What are the degrees of Spondylolithesis

Answer 11

1: <25% translation
2: <50% translastion
3: <75% translation
4: 100% translation
(talking about degrees of slippage)

Question 12

How do you treat Spondylolithesis

Answer 12

APAP (not inflammatory process!) 
NSAIDS (caution in long term use 2/2 metabolism in kidneys), Opioids (breakthrough pain) 
Weight loss 
PT
Epidural injections 
Laminectomy, vertebral fusion

Question 13

What does this scenario describe:
17 y/o varsity presents w/ b/l low back pain, initially left sided but gradually worsening over 3 months. Pain worse w/ activity and constant. No night Sx. Ibuprofen helps take the edge off. Recently started spring lifting program and football drills
PE: No antalgic gait, pain w/ standing or flexion, scoliosis, or kyphosis. Negative straight leg and seated slump test. L1-L5 dermatomes, myotomes and reflexes symmetric b/l. Positive stork test on right

Answer 13

Spondylosis!
A defect in the pars interarticularis of lumbar vertebrae (ex: a fracture)
Typically no neuro or radiculopathy Sx
W>M

Question 14

What is the stork test

Answer 14

Have pt balance on one leg, extend, and turn towards lifted leg (side you are testing). You stand behind them for support. Test both sides

Question 15

Extension tests

Answer 15

Facet joints!

If they are inflamed or rubbing, it will cause pain

Question 16

What can cause fracture of the interarticularis pars

Answer 16

Overloading with load bearing, upright, and weight bearing activities
Trunk extension/hyperextensino
Extension and rotation (why we use the stork test!)

Question 17

What sports are high risk for Spondylosis

Answer 17

classic ballet 
Gymnastics 
Figure skating 
Football linemen 
Diving

Question 18

What symptoms indicate we should be concerned about spondylosis

Answer 18

Pain persists

Can progress to spondylolithesis (forward movement of one vertebrae on another)

Question 19

How can you evaluate Spondylosis

Answer 19

Plain XR: Lateral view (most sensitive) Lateral Oblique (most specific), or AP view

Question 20

Lateral oblique view of Spondylosis will show

Answer 20

Scotty dog defect!
On this view, you see a dog shape on every vertebrae. But the affected one has a line in it for the fracture, that makes it look like the collar on a scotty dog

Question 21

What can cause a stress reaction

Answer 21

Repetitive mechanical stress (trunk extension and rotation)

Question 22

What is the pathology behind a stress reaction

Answer 22

Maladaptive response to repetitive stress; Osteoclasts>Osteoblasts so bone remodeling accelerates
-Must r/o bone pathology as cause!*

Question 23

What stimulates osteoblasts

Answer 23

weight bearing activity
growth
fluoride
electricity

Question 24

What inhibits osteoblasts

Answer 24

No chronic weight bearing 
chronic malnutrition 
alcoholism 
chronic disease 
normal aging 
hypercortisolism

Question 25

What Inhibits withdrawal of osteoclasts (ex promotes growth)

Answer 25

weight bearing
estrogentestosterone
calcitonin
adequate vitamin D and calcium

Question 26

What stimulates withdrawal of osteoclasts (ex bone breakdown)

Answer 26

no weight bearing 
space travel 
hyperPTH
Hypercortisol
hyperthyroid
estrogen deficiency (menopause) 
testosterone deficiency 
acidosis
myeloma
lymphoma
normal aging
not enough calcium intake

Question 27

Stress reactions lead to

Answer 27

Microfractures
Initiation of inflammatory response
bone stress injury causing stress fracture

Question 28

How do you grade stress reactions

Answer 28

I: periosteal edema
II-III: varying severity bone marrow edema
IV: cortical fracture line

Question 29

What imaging does a stress reaction warrant

Answer 29

MRI!

after an MRI you can get a bone scan which will show black spots where affected

Question 30

How do you treat stress reactions/Spondylosis

Answer 30

Activity restrict 1-4 wks
PT during week 5-12 (work on core strength and LE flexibility)
Gradually return to activity during wk 9-12
Full activity after wk 12
Consider brace

Question 31

When would surgery be an option for Spondylosis

Answer 31

Grade III-IV spondylolithesis (75%+)