LBP and C-Spine Flashcards
What is the MCC of LBP?
Somatic Dysfunction (lumbar strain)
NEXUS criteria for clearing a cervical spine injury
- no midline cervical tenderness
- no focal neuro deficits
- normal alertness
- no intoxication
- no painful distracting injuries
Brachial Plexus Injury
compression or distraction force
Compression Force
nerve roots pinched between adjacent vertebrae
Distraction Force
tension or “stretch” force on nerve roots
What is the most common level for a distraction force brachial plexus injury to occur?
C5/C6
What is Erb’s point?
2-3 cm above clavicle anterior to C6 transverse process, most superficial passage of brachial plexus
Signs and Symptoms of Brachial Plexus Injury
- immediate and significant pain
- burning, achy pain
- dropped shoulder on affected side
- symptoms minimize or resolve quickly
Where are the most common disc herniations of the cervical spine?
C5/C6 or C6/C7
Spain/Strain Signs and Symptoms
- limited ROM
- occipital headaches and diffuse tenderness
- no peripheral pain or paresthesia
- normal neurological exam
Vertebral Artery Impingement
due to anatomic location, may be compromised with same mechanism of injury as brachial plexus/cervical nerve root impingement injuries
Vertebral Artery Impingement - signs and symptoms
- dizziness
- confusion
- nystagmus
Syrigomyelia
- cyst in the spinal cord that elongated over time
- compresses nerve fibers and leads to progressive arm and leg weakness associated with headache and cold sensation of the hands with loss of bladder function
Cervical Spondylosis
degenerative disorder of the disc with ingrowth of bone with side spurs and thickening of the ligament
Cervical Spondylosis - signs and symptoms
- causes pain and radiculopathy with limited mobility in the upright position
- paresthesia in hands and hand dexterity
- loss of vibratory and position sense in the feet and legs
How many vertebrae’s does the lumbar spin consist of?
5 (L1-L5)
What type of curve does the lumbar spin have?
Lordotic curve
What type of curve does the sacrum have?
Kyphotic curve
What are the anterior and posterior longitudinal ligaments?
Long ligaments that run the length of thevertebral column, covering the vertebral bodies and intervertebral discs.
The ligament flavum connects what?
Connects the laminae of adjacent vertebrae.
The interspinous ligament connects what?
Connects the spinous processes of adjacent vertebrae.
The supraspinous ligament connects what?
Connects the tips of adjacent spinous processes.
What are the red flags for LBP?
- Age < 15 or > 50
- Fever, chills, UTI
- Significant trauma
- Unrelenting night pain; pain at rest
- Progressive sensory deficit
- Neurologic deficits
- Saddle-area anesthesia
- Urinary and/or fecal incontinence
- Major motor weakness
- Unexplained weight loss
- Hx or suspicion of Cancer
- Hx of Osteoporosis
- Hx of IV drug use, steroid use, immunosuppression
- Failure to improve after 6 weeks conservative tx
What is the mechanical cause of LBP?
- Musculo-ligamentous strain
- Degenerative joint/disc disease
- Herniated lumbar disc
- Spondylolisthesis
- Spinal stenosis.
What is the inflammatory cause of LBP?
- Ankylosing spondylitis
- Inflammatory bowel disease
- Psoriatic arthritis
- Polymyalgia rheumatica
What is the infectious cause of LBP?
- Pyogenic or tuberculous osteomyelitis
- Epidural abscess
Dysfunction involving what can create LBP?
- T spine
- L spine
- SI joint
- Hip
What are the indications for an MRI?
- Possible cancer, infection, cauda equina synd
- > 6-12 weeks of pain
- Pre-surgery or invasive therapy
What imaging is done for Cauda Equina?
- MRI STAT —> Neurosurgery consult
- Fracture: x-rays
What are the 3 steps for PE of the LS spine?
- Observation
- Palpation
- Range of motion
What is “observed” during the observation step of the PE?
- Pain behaviors–groaning, position changes, grimacing, etc
- Atrophy, swelling, asymmetry, color changes
- Calor, rubor, tumor
What is palpated during the palpation step of the PE?
- Palpate area of pain for temperature, spasm, and pain provocation
- Point palpation for trigger points/tender points
What is done during ROM step of the PE?
- Active and passive
- Flexion, extension, rotational, lateral bending
- Leg raising
What is Cauda Equina Syndrome?
Injury to multiple lumbosacral nerve roots in the spinal canal distal to L1-2 terminus
- Rare, needs emergent surgical referral
What is the etiology of Cauda Equina Syndrome?
Massive midline disc herniation (HNP) or mass compressing cord or cauda equina (tumors), fractures, and hematoma following lumbar puncture
What is the S/Sxs of Cauda Equina Syndrome?
- LBP
- Bilateral lower extremity weakness
- Numbness, or progressive neurological deficit
- Saddle anesthesia
- Loss of bladder control
What is the PE findings of Cauda Equina Syndrome?
- Observe gait
+ leg raise test
+ walking on heels or toes - Evaluate motor and sensory fxn of lumbosacral nerve roots including anal sphincter tone and or perianal numbness.
What imaging is done for Cauda Equina Syndrome?
MRI
What is the tx for Cauda Equina Syndrome?
- Surgical emergency
- Immediate decompression once lesions has been defined.
What is the etiology of a herniated disk?
- Overload (direct or indirect) or faulty biomechanics (or both)
- Protrusion, prolapse, extrusion, and sequestration.
What are the S/Sx of a herniated disk?
- Pain aggravated by activity
- Prolonged body position increases sxs
- Local and radiating pain
What is the imaging done for a herniated disk?
MRI
What is the tx for a herniated disk?
PT, stretching to help releave pressure on nerve root, manipulation, NSAIDS
What is the etiology for Lumbosacral radiculopathy?
Damage to specific nerve root and/or herniated disk
What is the sxs for Lumbosacral radiculopathy?
Pain radiates along the nerve down the lower extremity (often manifests as sciatica)
What is the PE for Lumbosacral radiculopathy?
If damage/herniation is located above nerve root and pt leans to that side it will cause pain on side of herniation, if damage is below the nerve root and pt leans to opposite side it will cause pain on herniated side.
What is sciatica?
- Inflammation of sciatic nerve
What is the etiology for sciatica?
Sciatica is a result and NOT an injury in and of itself, need to find what is the cause of the irritation
What are the risk factors of sciatica?
- Age
- Obesity
- Occupation
- Prolonged sitting
- Diabetes
What are the S/Sxs of sciatica?
Pain below knee pain that radiates along the path of this nerve — from your back down your buttock and leg.
What are the PE test for sciatica?
Straight leg raise, may have abnl neuro exam
What is the tx for sciatica?
- Conservative treatments in a few weeks.
- People who continue to have severe sciatica after 6 weeks of tx may need surgery to relieve the pressure on the nerve.
What is spinal stenosis?
Degenerative narrowed spinal canal, asymptomatic in development.
What is the etiology of spinal stenosis?
Neurogenic Claudication
What are the S/Sxs of spinal stenosis?
- Pain radiates to leg
- Pain worse w/ standing or walking
- Pain reduced with flexed spinal positions-sitting
- Can be bilateral
What is the PE test for spinal stenosis?
- Leg weakness is uncommon
- Proprioception may be impaired
- Diminished reflexes
What is the dx test for spinal stenosis?
- Conservative-plain films may show spondylolisthesis or significant narrowing of intervertebral disk
- osteopenia maybe present
What is the tx for spinal stenosis?
- PT, follow in 2-4 weeks for progress
- If no improvement by 6-12 weeks: MRI, refer for interventions.
- Epidural steroid injections for radiculopathy
- Surgery if/when it affects ADLS
What is Foraminal Stenosis?
Degenerative and like spinal stenosis
What is the etiology of Foraminal Stenosis?
- Can be associated w/ lateral disc protrusions, osteophytes, tumors, or unilateral nerve root compression (like HNP)
What imaging is done for Foraminal Stenosis?
CT or MRI
What is the tx for Foraminal Stenosis?
surgery for neural compromised
What is Spondylolysis?
Changes in the vertebral joint characterized by increasing degeneration of the intervertebral disc with subsequent changes in the bones and soft tissues.
What is the etiology for Spondylolysis?
Unilateral or bilateral stable defect in the pars interarticularis
What imaging is done for Spondylolysis?
XR- “Collared Scottie dog” deformity
What is the cause of Spondylolisthesis?
- Unstable Spondylolysis
- Bilateral defect in the pars interarticularis which causes forward displacement of vertebra.
What imaging is done for Spondylolisthesis?
XR -“Decapitated Scottie dog” deformity, step off deformity
What is the the tx for Spondylolisthesis?
- REST and ice
- Flexion is best.
- Reduce extension moments.
- Bracing
- Surgical treatment with advanced cases: Traumatic, degenerative, isthmic, pathologic, dysplastic types
Wha is ankylosing spondylitis?
- A form of inflammatory arthritis
- Immune mediated associated with the axial spine esp SI joint
What does ankylosing spondylitis cause?
- Primarily causes inflammation of the joints between the vertebrae of your spine and the joints between your spine and pelvis (sacroiliac joints).
What are S/SX of ankylosing spondylitis?
Early adults (males) with low back am stiffness sx -insidious
What imaging is done for ankylosing spondylitis?
- Xray with sacroilitis to bamboo spine and complicated by fracture (cervical)
What can ankylosis spondylitis effect?
Can effect the eyes, colon and ileum, skin and heart (AI-CHF), anemia, ESR/CRP, HLA-B27, Alk Phos
What is the tx for ankylosis spondylitis?
- NSAIDs
- Refer to rheum for anti-TNF
- Monitor distal sites and refer
Polymyalgia Rheumatica is MC’ly seen in who and is associated with what?
- Men above 65
- Giant Cell Arteritis association
What are the S/Sx of Polymyalgia Rheumatica?
Severe pain and associated with the BL joints and common in the hips
What are the Dx test for Polymyalgia Rheumatica?
- No XR findings
- Elevated ESR
What is the Tx for Polymyalgia Rheumatica?
- Prednisone 20mg daily,
- Ca and Vit D
- Anti –TNF or Methotrexate
What length of time is considered chronic LBP?
> 6 weeks and/or non-responsive to tx
What evaluations is done for chronic LBP?
- X-rays, labs
- Evaluate for “YELLOW FLAGS”
What is the management for chronic LBP?
- Medication selection
- Interventions
What is the tx for chronic LBP?
- Most do NOT benefit from surgery
- Should have ANATOMIC LESION C/W PAIN DISTRIBUTION
- Significant functional disability, unrelenting pain
- Several months despite conservative tx
- Procedures: spinal fusion, spinal decompression, nerve root decompression, disc arthroplasty, intradiscal electrothermal therapy
What are the MC levels of herniation?
- L4-L5 disc: 5th lumbar nerve root
- L5-S1 disc: 1st sacral nerve root
With a L4-L5 herniation, where is the pain?
Over sacroiliac joint, hip, lateral thigh, and leg
With a L4-L5 herniation, where is the numbness?
Lateral leg, first 3 toes
With a L4-L5 herniation, where is the weakness?
- Dorsiflexion of great toe and foot
- Difficulty walking on heels
- Foot drop may occur
With a L4-L5 herniation, is there atrophy?
Minor atrophy
With a L4-L5 herniation, are the reflex diminished/absent?
Only in the internal hamstring
With a L5-S1 herniation, where is the pain?
Over sacroiliac joint, hip, posterolateral thigh leg to the heel
With a L5-S1 herniation, where is the numbness?
- Back of calf
- lateral heel
- Foot to toe
With a L5-S1 herniation, where is the weakness?
- Plantar flexion of foot and great toe
- difficulty walking on toes
With a L5-S1 herniation, is there atrophy?
Yes at the gastrocnemius and soleus
With a L5-S1 herniation, are the reflex diminished/absent?
Ankle reflex diminished/absent.
