Lecture 12: Back and Neck Disorders Flashcards
Red flags for a Neck and Back Exam Include:
- Age < () or > ()
- Duration of greater than () months
- pain at ()
- Long term use of (drug)
- Hx of ()
- () positive
- Age < 20 or > 50
- Duration > 1 month
- Pain at night
- Long-term steroid use
- Hx of IVDU, addiction, or immunosuppression
- HIV +
A way to remember the red flags of neck and back pain is via the mnemonic TUNAFISH, which stands for:
- T()
- () wt loss
- () Symptoms
- () < 20 or > 50
- F()
- I()
- () use
- () of cancer
- Trauma
- Unexplained wt loss
- Neurologic symptoms
- Age < 20 or > 50
- Fever
- IVDU
- Steroid use
- Hx of Cancer
Back pain that IMPROVES with activity is most likely…
Ankylosing spondylitis
Lower back pain that radiates down the butt and below the knee is probably…
Nerve root compression
You should consider a () in your DDx for someone with IVDU and recent back pain.
Epidural abscess
Pain with neurogenic claudication is suggestive of…
Lumbar spinal stenosis
The nerves corresponding to upper extremity testing are.. (4)
C5-8
Brachial plexus
The 3 primary nerves making up lower extremity testing are…
L4, L5, S1
A positive Straight Leg Raise is suggested by () pain on () side
Worsening radicular pain on affected side. Suggests a herniated disc compressing a nerve root.
A positive CROSSED SLR is when you can reproduce () pain in the () leg when the () leg is raised.
Reproduction of radicular pain in the affected leg by RAISING THE UNAFFECTED LEG.
AKA pain in R leg when you lift left leg. R leg has radicular pain.
A positive trendelenburg test is when you see a pelvic drop below neutral. Which side indicates inadequate gluteus medius strength?
The stance side!
The straight limb is the WEAK ONE
A positive babinski test in an adult is when () extends and the other toes (). It indicates () lesion
- 1st toe extends
- Toes 2-5 fan out
- Indicates a long-tract/Upper moton neuron spinal cord lesion
An ankle clonus test is indicated if () is abnormal. A positive ankle clonus produces clonus (hehe). This indicates a () lesion.
- Achilles tendon reflex abnormality
- Indicates a long-tract spinal cord lesion
At least () out of the 4 Waddell’s tests suggests low likelihood of injections/surgical intervention success.
3/4
The 4 key components of a gait assessment are to check:
- () gait
- () to ()
- () only
- () only
- Standard gait
- Heel to toe
- Heels only (L4/L5)
- Toes only (S1)
Best performed barefoot
The initial imaging modality for Atraumatic C-spine is…
XR
See slide for all the specifics about extra views
The initial imaging modality for Trauma patients for C-spine is…
CT C-spine
You can locate C7 on the swimmer’s C-spine XR by looking for what bony landmark?
1st rib
Lumbar spine XR add on an oblique view, which has a characteristic () sign
Scotty dog
The MCC of Lost work time and disability in YOUNG ADULTS is…
Acute LBP
MC strained area of the body!
ACute lower back pain is characterized by:
- () into the butt and posterior thighs
- () with movement
- transient improvement with () changes
- Radiation into butt/thighs
- Worsens with movement
- Improves transiently with positional changes
T/F: Reflexes, motor, and sensory exam for acute LBP are normal.
True.
T/F: ROM is normal on acute LBP.
False.
Generally, you should only order a Lumbar XR in:
- Hx of ()
- () pain
- () pain
- night sweats
- Hx of significant trauma
- Atypical pain
- Nocturnal pain
- Night sweats
T/F: Disc space narrowing and bone spurs on a Lumbar XR for a patient aged over 30 is indicative of a pathologic process.
FALSEEEEEE
Patient education/management of acute LBP is:
- Avoid ()
- Avoid ()
- (drugs)
- () if evidence of muscle spasm on exam
- Avoid intense physical activity
- Avoid BEDREST; no more than 2d
- NSAIDs/Tylenol for pain
- Muscle relaxants only if spasms
Also heat, massage, acupuncture
You would refer for acute LBP in two circumstances:
- Evidence of () symptoms on exam
- Unable to return to work after () weeks
- Evidence of neurological dysfunction (get MRI and refer to neurospine)
- 4 weeks
Your patient asks you how long to expect their acute LBP to last. You tell them to expect pain resolution in about…
1 month
Order imaging if not improved and no previous imaging.
Chronic back pain is back pain that lasts > () weeks
12 weeks or more
The MC underlying cause of chronic LBP is…
Degeneration of the intervertebral structures
Besides the aching/pain of chronic LBP, associated () is often a hallmark symptom.
Stiffness
T/F: Reflexes, motor, and sensory exam for chronic LBP is normal.
True
T/F: anterior osteophytes and reduced intervetebral disc height is normal as you age. (as seen on lumbar XR)
True!
For chronic LBP, the usual referral is to…
Pain management
Cervical strain is MC caused by () and involves damage to the () spinal muscles and () of the facet joints.
- MCC: Whiplash/flexion-extension injury.
- Paravertebral spinal muscles
- Ligaments of facet joints
T/F: Reflexes, motor, and sensory exam is ABnormal for cervical strain.
False :)
Cervical strain is often associated with () spasms and () headaches
- Paraspinal spasms
- Occipital Headaches
Cervical strain pain is (diffuse/local) and (radicular/nonradicular)
Diffuse and nonradicular
Worsened by movement
Cervical strain
You should order a 3-view C-spine XR for:
- Hx of ()
- Associated () deficit
- (age)
AP, lateral, Odontoid view
- Hx of trauma
- Associated neuro deficit
- Elderly
Make sure you see all 7 C vertebrae!
You would expect a NORMAL XR for simple cervical strain.
Initial care for a cervical strain:
- () + mild narcotic +/- NSAIDs for 1-2 weeks
- () if spasms
- () at night
- Soft cervical collar
- Muscle relaxants
- Cervical pillow
You forsure MELLERT WILL ASK THIS
You should never () in acute cervical strain injuries.
Manipulate the C-spine
Your patient with cervical strain not due to whiplash asks how long it will take them to feel 100%. You tell them ()
4-6 weeks
Whiplash might take a year
C1 is the (atlas/axis)
C1 is the atlas
Atlas holds up the world (your head) in greek mythology
There are 3 ways to get a C-spine fx:
- () trauma
- () ROM injury
- () injury
- High-energy trauma
- Extreme ROM injury
- Vertical/Axial compression injury
In anyone with cervical trauma, you should…
RULE OUT C-SPINE FX
A hangman’s fx is of C() and involves bilateral fractures of the pedicles or ()
C2 fx with bilateral fx of pedicles/pars interarticularis
The 2 C2 fractures are…
- Hangman’s fracture
- Odontoid/Dens fracture
There are 3 types of Odontoid(C2) fractures. The BEST prognosis type is…
Type 3
There are 3 main types of fractures when it comes to C3-C7. Their MOIs are:
- Compression
- Flexion-extension distraction
- Rotation
The usual symptom of a C-spine fracture is (), but you should remember that a lot of missed fractures are because they never showed this symptom.
Severe neck pain
Your suspected C-spine fx pt is having severe neck pain AND focal UE numbness/tingling. You suspect that there is also associated ()
Nerve root impingement
A patient walks into the ED having just gotten into a MVA. They complain of severe neck pain and feel numb in both their arms. Your initial intervention is to…
Put them in a C-collar and backboard
As you assess your MVA patient for point tenderness in their C-spine, you notice a gap/step off between their spinous processes. You know this can either mean a () injury or a fractured ().
- Ligamentous injury
- Fractured Pars
As you perform a neuro exam on a MVA patient, you check their sphincter tone, which is absent. Their anal reflex is also absent. You suspect that they have a spinal cord lesion above the level of () to () at minimum.
S2-S4 or higher
The difference between spondylolysis vs spondylolisthesis is…
Listhesis is a full on displacement
NEXUS criteria for C-spine is only used in patients with….
GCS 15
Meeting all 5 NEXUS criteria rules out need for imaging and removal of C-collar. The 5 criteria use the mnemonic NSAID.
- Neuro deficit
- Spinal tenderness midline
- AMS
- Intoxicated
- Distracting injury
Initial imaging modality for mod-severe traumatized C-spine or with abnormal initial XR is…
Non-con CT of the spine
C-spine XR is used in lower-mod risk trauma patients. You are looking for either () or ()
- Fracture
- Signs of instability
Signs of instability on C-spine XR is indicated by either:
- Translation of vertebral body by more than () mm
- () degrees of angulation of adjacent vertebral bodies
- 3.5 mm
- 11 degrees
You would only do MRI or MRA in a C-spine fracture workup if you are worried for () or ()
Spinal cord or vetebral artery injury
AKA global deficits like CES?
In management of C-spine Fx, () are controversial, but referral to () is indicated, along with () control
- IV steroids = controversial
- Consult ortho/neurosurg
- Pain control
If you have normal neuro exam and imaging for a C-spine fx but still suspect an occult fx, you can place a () for 7-10 days and then () afterwards and repeat ()
- Place a soft cervical collar
- Re-eval and repeat XRs
Halo-vest immobilization is considered in () C-spine Fractures.
Stable fx
Patients with () or () may get a thoracolumbar fx with minimal trauma.
- Cancer
- Osteoporosis
You would expect a thoracolumbar fracture to present with () back pain and () symptoms if they had a nerve root/spinal cord injury.
- Mod-severe back pain
- Neurologic symptoms
Presence of step off during spinous process palpation in a thoracolumbar spine fx is indicative of…
Unstable fx
Spondylolisthesis?
When doing a physical assessment on a thoracolumbar injury, you should use the () technique
Log-roll
You have a patient that presents with a mild thoracolumbar injury. Your initial imaging modality of choice is (). If its abnormal or mod-severe, you would then order a ()
- XR
- Non-con CT
Your patient with a thoracolumbar vertebral fracture is evaluated with XR and it shows an isolated, transverse process fx. Your management for this patient is ()
Thoracolumbar corset
Oh you know shes gunna ask this
Your patient with a thoracolumbar vertebral fx is evaluated and it shows a stable, simple compression fracture of less than 20 deg. Your recommended management for this patient is…
Thoracolumbosacral orthosis (TLSO) for 8-12 weeks
Surgical decompression is the management for more severe thoracolumbar vertebral fractures. The more severe/indications for calling ortho/neurospine are:
- () fractures
- flexion-distraction/dislocation
- () compression injuries
- Burst fractures
- Severe compression
() is like putting cement into a vertebrae
Kyphoplasty
2 screws and a rod in the vertebrae describe ()
Vertebral fusions
Congenital torticollis (rare) is caused by damage to the () muscle
SCM
The MCC of acquired torticollis is…
Blunt trauma or awkward sleeping position
The two medication/drug classes that can induce torticollis are () and ()
- Antipsychotics: Haldol
- Antiemetics: Reglan
The 3 muscles involved in torticollis, a contraction/spasm of the neck muscles, are:
- SCM
- Posterior cervical
- Trapezius
Initial management of a patien presenting with torticollis is:
- Removal of ()
- (drugs), (drugs), (more drugs)
- Removal of underlying cause
- NSAIDs, Benzos, Muscle relaxants
Your patient has tried NSAIDs, benzos, and muscle relaxants for their torticollis, but it won’t go away! You try (). If this fails, your last option is…
- Try Botox
- Surgical release of SCM, denervation or stimulation
Spinal stenosis is narrowing of the () at 1+ levels with subsequent compression of the nerve roots.
Intraspinal/central canal
There are 5 general etiologies for spinal stenosis:
- () changes
- () occupying lesions
- () fibrosis
- () diseases like Paget’s, Ankylosing, or RA
- () conditions like dwarfism or spina bifida
- Degenerative changes
- Space occupying lesions
- Post-op/traumatic fibrosis
- Skeletal diseases
- Congenital conditions
You have an older patient who presents with discomfort, sensory loss, and weakness in both their legs when walking. It gets worse when they extend their spine. It gets better when they sit, flex their waist, or lay down. This describes (symptom), which is the classic symptom of ()
- Neurogenic claudication
- Spinal stenosis
In () claudication, peripheral pulses are normal. In () claudication, they are abnormal.
- Neurogenic claudication = normal peripheral.
- Vascular claudication = abnormal peripheral pulses.
Physical exam of spinal stenosis can sometimes be positive for a (special test), which can throw you off.
SLR
What exam MUST you do to differentiate prostate/stress incontinence from spinal disease?
GU exam
The modality of choice for diagnosis of spinal stenosis is (), backup to it is ()
- MRI is choice
- CT w/ myelography is 2nd choice if MRI is CI
First-line therapy for spinal stenosis is…
Conservative, non-surgical therapy consisting of PT, water aerobics, and NSAIDs + epidural steroids
You should refer your spinal stenosis patient to surgery if…
- symptoms cause difficulty () or () QOL
- Evidence of () deficit, () dysfunction
- Difficulty ambulating
- Decreased QOL
- Evidence of Neuro deficit
- Bowel/bladder dysfunction
- Average age of onset: 15-25y
- Male preference
- Axial skeleton stiffening
- Enthesitis with chronic inflammation via T-cells
Describe what
Ankylosing spondylitis
The back pain and morning stiffness of ankylosing spondylitis () with activity.
Improves
The Hallmark sign of ankylosing spondylitis is…
Enthesopathy
Besides the spine, the MC organ affected in ankylosing spondylitis is…
Eye: anterior uveitis
HLA-B27 is (diagnostic/not) of ankylosing spondylitis
Not diagnostic!
The inflammatory markers present in 85% of ankylosing spondylitis patients are…
ESR and CRP
Bamboo spine and shiny corner sign are typically not seen on lumbar XR until () years. Instead, you can order a … to show evidence.
- 2 years after S/S onset
- MRI will show evidence within first 2 years!!
Ankylosing spondylitis
Calcifications or heterotrophic ossifications inside a spinal liagment or annulus fibrosis describe…
Syndesmophytes
First-line tx for ankylosing spondylitis is…
NSAIDs! + PT
The 2nd line tx for ankylosing spondylitis is
anti-TNF agents!
entanercept/enbrel, infliximab/remicade, adalimumab/humira
Indicated in NSAID resistant
A herniated disc is a protrusion of the (nucleus pulposus/annulus fibrosis)
Nucleus pulposus
Herniated discs occur most commonly between the levels of () and () or () and ()
- L4-L5
- L5-S1
Most people would describe their herniated disc pain as (timing) and () pain into the buttocks/legs. Usually the most comfortable position is ()
- Sudden, abrupt, severe
- Shooting/stabbing pain
- No comfortable position :(
T/F: A positive SLR is seen for herniated discs.
Trueee
An XR for a herniated disc will show ()
Literally nothing
MRIs for herniated discs are indicated in 4 cases:
- Symptoms persist for more than () weeks
- Significant () deficit
- Progressive () changes
- () pain
- Greater than 4 weeks
- Neuro deficits
- Progressive neuro changes
- Intolerable pain
Management of a herniated disc:
- (drugs)
- (drugs)
- rest/activity modification
- PT once ()
- NSAIDs
- Oral prednisone
- PT once pain free
Opiates only for severe, intolerable that is NSAID resistant
You should REFER for a herniated disc if:
- Emergent referral if () deficit or () syndrome
- Lack of improvement after () weeks
- () episodes that affect QOL
- Focal neuro deficits or CES
- 3-4 weeks no improvement
- recurrent episodes
Cauda Equina is made of up what nerve roots?
L2-L4
CES is a () condition and will result in () neurologic dysfunction if left untreated
Emergent condition resulting in permanent neurologic dysfunction
SPINE is the mnemonic for CES, and it stands for…
- Saddle anesthesia
- Pain in lower back
- Incontinence
- Numbness of groin/legs
- Emergency!!!
The imaging of choice for CES is…
Emergent MRI w/ gadolinum contrast
CT and myelography if MRI nogo
Surgical decompression of CES is required within () to () hours of onset
12-24 hours of onset
MCC of sciatica is…
Herniated disc
Honestly its practically just a symptom of a herniated disc.
Management and everything is the same.
Kyphosis is a curvature of the () spine
Thoracic spine
The XR finding associated with kyphosis is…
Increased kyphotic cobb angle > 40deg
Normal is 20-40 so im guessing she means > 40deg
Kyphosis is managed primarily through:
- (drug)
- Back strengthening exercises
- ()
- Referral for possible surgical management
- NSAIDs & muscle relaxants
- Bracing
The IV form of Robaxin is contraindicated in…
- Seizure d/o
- Renal impairment
Generally, all muscle relaxants cause () and should be used in caution with the ()
- CNS depression on some scale
- Elderly
