Lumbar spine Flashcards
Where do cervical nerve roots exit the spinal canal
Above the pedicle of the corresponding vertebrae
Where do lumbar nerve roots exit the spinal Canal
Below the corresponding pedicle
What motor function does T1-T6 control in the body
Trunk and intercostals
What part of the spine have control of abdominal muscles
T7-L1
Why is it hard to determine which nerve is effected when located in the T-Spine
Overlying dermatoses make it hard to differentiate
What pathology are you most concerned about in regards to the T-Spine
Fractures
SCI
Pediatric deformity
Scoliosis
What lumbar nerve control hip flexion and hip adduction
L2, L3
What does the L4 nerve control
Patellar reflex
What Lumbar motor nerve control ankle dorsiflexion, hip extension, hip abduction
L5
What does the S1 nerve control
Achilles reflex
What nerves are in control of sphincter tone
S5
What does the babinski reflex test
A central pathology (brain + spinal cord)
What does a normal babinski test look like
Run a sharp instrument from heel to toe
- a normal test = flexion of toes
What is the babinski sign
When the toes flex with the babinski test
What does sustained ankle clonus indicate
Spinal cord pathology
What is the FABER test
hip Flexed to 90 degrees
ABduct &
Externally
Rotated
What is the FABER test used for
Differentiate between hip and sacral pain
If there is back pain for the FABER test, what is it indicative of
SI joint dysfunction
If there is groin pain with the FABER test, what is it indicative of
Hip pathology
What are some lumbosacral tests
Faber
Straight leg raise
What is a positive straight leg raise
Having radicular pain between 30-70 degrees of hip flexion
What is the gold standard for diagnosing back pain
MRI
When is MRI with contrast used for confirming back pain diagnosis
Had previous surgery
suspicion / Hx of cancer
Concern of infection
When can an MRI be ordered for back pain
Failure of at least 1 month of conservative management
What are red flags that allow for immediate MRI for back pain
Cauda Equina sx
H/O IVDU
associated fever/chills
H/O or concern for cancer
H/O trauma
What test is ordered if an MRI with contrast can not be done
CT angio
What test can help pinpoint which nerve or pathway is compressed
EMG / NCV
What is the treatment buffet for back pain
Heat / rest/ ice
PT / home exercise
Alternative treatment
Bracing (peds only)
Medications
injections
surgery
Why is bracing avoided in adults when there is no deformity or fracture
Chronic brace use can exacerbate pain descondary to reconditioning
What is the top pain medication to recommend for patients with back pain
Tylenol (acetaminophen)
Which anti-inflammatories can someone take with back pain
Aleve / Advil
Diclofenac, meloxicam, etodolac, indomethacin
Celecoxib
When are NSAIDs contraindicated for patients
CKD
DM
Caution for heart disease
What medications can be given for nerve pain
gabapentin
Pregabalin
What is important to remember if gabapentin is prescribed
There are many side effects
Cannot stop abruptly - must wean
-> lowers seizure potential
When can pregabalin be prescribed
After a failed trail with gabapentin
What type of muscle relaxers can be prescribed for patients
Cyclobenzaprine
methocarbamol
tizanidine
Carisoprodol (soma)
Benzodiazepines
What are some types of Benzodiazepines
Valium / Diazepam
Alproxolam / Xanax
What are controlled substance muscle relaxers
Carisoprodol(soma)
Benzodiazepine
What are side effects with muscle relaxers
Respiratory depression, especially with concurrent pain meds / elderly patients
What type of medications help with night time nerve pain
Nortriptyline
TCA medication
* both are tricyclic antidepressants
What do you have to be careful with / aware of with trycyclic antidepressants
Can OD on these
What antidepressants can be prescribed for chronic pain
SNRI
Duloxetine
What steroids can you use for acute pain
Methylprednisolone
What is important to remember when prescribing steroids
Must taper the dose - don’t stop abruptly
What is the perk of using methylprednisolone
A medrol dose pack is already tapered for you
Which patients have poor outcomes with surgery on LSpine
Nicotine use
Uncontrolled DM
BMI > 40
Chronic narcotic use
How will a lumbar sprain present
Deep steady pain in the low back -> often with overuse
How long should it take a lumbar strain to resolve
6 weeks -> if still in pain, investigate with imaging and more tests
What is another name for degenerative disc disease
Spondylosis
What is axial low back pain
Pain that remains in lower back
If a patient presents with axial low back pain for >12 weeks that is exacerbated by specific positions and movements, what might this patients diagnosis be
degenerative disc disease
What is the first line imaging for spondylosis
Xray
What is the diagnostic test of choice for DDD
MRI
Is radiculopathy a symptom or a diagnosis
Symptom
What is radiculopathy
nerve root irritation
What is radiculopathy of the sciatic nerve called
sciatica
What is sciatica often secondary to
Herniated disc
What nerves come together to form the sciatic nerve
L4 - S3
What exam will be positive with sciatica
Straight leg raise
*must differentiate from muscular pain
Which gender is more apt to get a herniated disc
Men 2:1
What causes a herniated disc
a tear in the annulus that allows for the nucleus to leak out
What level of the L-spine is most often to see a herniated disc in
L4-5
L5-S1
A patient comes in with axial back pain with radicular complaints. They are unable to get comfortable in a chair and are more comfortable standing/walking. Recall a BLT event when the symptoms began. What is the likely diagnosis
Herniated disc
What can increase pain with a herniated disc in a physical exam
Coughing
sneezing
valsalva
What is the diagnostic modality of choice for herniated discs
MRI
If conservative treatment fails with herniated discs, what is the next line of treatment
Discectomy
How long does it take for a patient to start to feel better with a herniated disc
roughly 3 months
What is spinal stenosis
Narrowing of the spinal canal
What else is generally occurring with spinal stenosis
foramen stenosis
What is the #1 reason for spine surgery in patients >65y/o
spinal stenosis
What area of the spine do you most commonly see spinal stenosis
L4-L5
What is claudication
Fatiguability
What is the hallmark of lumbar stenosis
Neurogenic claudication
What is the diagnostic test of choice for spinal stenosis
MRI
What is spondylolysis
Defect in the pars
What makes up about 50% of adolescent back pain
Spondylolysis
What are the risk factors for spondylolysis
Repetitive hyperextension
Contact sports
What can spondylolysis lead to
spondylolisthesis
Where is spondylolysis typically seen
L5-S1
What symptoms do patients generally have IF they have symptoms with spondylolysis
Insidious onset back pain, worse with activity
What will you see in a physical exam with someone who has spondylolysis
Limited lumbar flexion/extension
Pain with single leg lumbar extension
What imaging is useful for delineating spondylolysis
CT
What is the most sensitive test for Spondylolysis
Bone scan
If a patient has progressed to spondylolisthesis or has refractory pain, what is the treatment option
Lumbar fusion
What grade of spondylolisthesis is seen with complete dissociation
Grade 5
What is the first line of diagnostic tests is used for spondylolisthesis
Xray
What is ankylosing spondylitis
Inflammatory condition of the spine
Who is usually at higher risk of developing ankylosing spondylitis
Caucasian males
What gene is associated with ankylosing spondylitis
HLA-B27
What is occurring in the spine with ankylosing spondylitis
Soft tissue ossification
Surrounding bone erosion
With is the diagnostic criteria for ankylosing spondylitis
Bilateral sacroilitis
Uveitis or Iritis
+HLA-B27
What does the Schober test measure
Spine ROM
-If no expansion with forward flexion-> positive test
What will ankylosing spondylitis look like on imagining
Bamboo spine
SI joint narrowing
Generalized osteopenia
What test can confirm sacroilitis in ankylosing spondylitis
SI joint corticosteroid injection
What will lab tests look like with ankylosing spondylitis
+HLA-B27
neg RF factor
Elevated ESR/CRP
how do you usually treat ankylosing spondylitis
Symptomatic treatment with TNF inhibitors
What gender and curvature is most common with scoliosis
Females
Right thoracic curvature
What is diagnostic on X-rays for scoliosis
> 10 degree Cobb angle
What scoliosis angle in growing kids is treated with surgery
> 60
What scoliosis angles in growing kids is surgery considered
50-60 degrees and symptomatic patients
What scoliosis curvature requires bracing in growing children
30-50 degrees
What skeletal angles in adults do you consider surgery
50 + degrees or if they’re symptomatic
What is cauda equina
Compression of cauda equina, in the L1-S5 region
What is the most common cause of cauda equina
Large disc herniations
Which gender and level is most common to have cauda equina syndrome
Males
L4-L5
What will cauda equina syndrome cause
Bowel / bladder dysfunction
Saddle anesthesia
Which patients are at higher risk for osteomyelitis
IVDU
Poorly controlled DM
Obese
Smokers
Immunosuppressed
What is the best imaging modality to diagnose osteomyelitis
MRI with contrast
When is surgical intervention needed with osteomyelitis
Unable to obtain IR bx
Abcess drain needed
Significant persistent deformity
How do you confirm an epidural access diagnosis
MRI with contrast
What is the treatment for an epidural abscess
emergent surgical decompression and send a culture and sensitivity
What will you see on labs in someone with an epidural abscess
Elevated WBC, ESR and CRP along with Bacteremia
