Medical Disorders of the Spine Flashcards
back and neck pain
o The third most common reason people visit their healthcare provider (after skin problems and joint pain)
o 80% Americans will experience back pain, and 28% will be disabled from back pain at some point
o In any given year, 8% of the American workforce will be disabled from back pain
o Back pain is the single largest cause of disability worldwide
differential dx of back pain
Mechanical causes
- Lumbar strain (70%)
- Degenerative disk disease – slowly over time the disks dry out, flatten, less cushion, causes more strain on soft tissues above and below the disks
- Spinal stenosis
- Disk herniation
- Spondylolisthesis
- Compression fracture
- Severe deformity (scoliosis, kyphosis)
Visceral or non-mechanical causes:
- Neoplasm
- Infection (diskitis, osteomyelitis)
- Ankylosing spondylitis
- Paget’s disease
- Prostatitis
- Dissecting aortic aneurism
- Pancreatitis
- Cholecystitis
- Gastric ulcer
- Nephrolithiasis
- Pelvic inflammatory disease
most common etiologies of acute back pain
o Muscle strain: self-limiting, often associated with heavy lifting or sudden deceleration injuyries; pain usually non-radiating
o Degenerative disk disease: develops slowly over time but acute event triggers disk rupture, tear, or herniation resulting discogenic back pain, may also have sciatica
o Fracture: 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)
“my back hurts”
o How did the pain start (sudden or gradual)
o Location, pattern intensity, and duration
o What makes it worse? Does it feel better with activity or with rest
o Leg/arm pain, weakness, or numbness? Problems walking?
o Bowel/bladder problems (we are worried about cauda equina)
o Hx of back pain: congenital spine problems, previous episodes of low back pain, previous back injuries
o Work/sports history. Is this a work-related injury? Any legal action related to your back pain
o General medical hx, including smoking, drinking, drug use, arthritis, cancer, malabsorption, arthritis, weight loss, fever
o Inspection: habitus, affect, posture, gait, active ROM
o Palpation: push your thumb on the spinous processes, not tenderness
o Strength: do a full strength exam, document any abnormal findings. Also a good time to do the “straight leg raise” test
o Sensation: do quick sensory exam, document any abnormal findings
o Reflexes: check patellar and achilles reflexes and for clonus. Then check biceps, brachioradialis, and Hoffman’s
o If concerned about carpal tunnel syndrome, check Tinel’s
charting strength and reflexes
Scale for grading strength
- 0/5 no movement/flaccid
- 1/5 barest flicker of movement/tone
- 2/5 cant overcome force of gravity – can move arm across the bed, but cant lift it up
- 3/5 can overcome gravity, but not any applied resistance – cant walk!
- 4/5 weaker than normal, but can overcome resistance – if you come in and can walk but youre weak
- 5/5 normal strength
Scale for grading reflexes
- 0 absent
- 1+ diminished but present
- 2+ average
- 3+ brisker than average
- 4+ very brisk/hyperactive
- For strength grading, you may chart with – or + to give a more nuanced picture (e.g., 3+/5)
scoliosis
o History: patient usually asymptomatic, usually found in school screening in the US; patient, family member or friend may notice shoulder asymmetry or waist asymmetry
o Physical exam: rib hump with patient bend forward, waist asymmetry, shoulder asymmetry
o Diagnostic studies: get a 36inch anterior/posterior x-ray. 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. X-rays should be done annually through puberty until the patient becomes skeletally mature (when the risk of progression is much lower)
o Treatment: regular physical exams by a spine surgeon or neurosurgeon to watch for progression. Bracing may be indicted 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
o Over time, disks degenerate. This is a common cause of chronic and recurrent low back and leg pain
o Most often at L4-L5 or L5-S1, but can involve any level of the lumbar spine
o Worse in those who have a history of heavy repetitive lifting, smoking, or driving
o 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
o 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
o The intervertebral disk: Acts as a shock absorber (for axial forces) and provides a pivot point for movement of the spine, Has two components: the outer annulus and inner nucleus pulposus
lumbar disk problems: history
o Pain! May have sudden or insidious onset. May have an associated event (liftin something heavy, falling, car accident, sneeze, etc.)
o Acute disk herniations generally cause more leg pain (i.e., nerve root pain), while degeneration generally causes more back pain
o Leg pain is dermatomal, may have numbness (paresthesias) and tingling. May also have weakness in a specific muscle group
o Herniations are usually self-limited (>90%) while degeneration will worsen over months or even years: The herniation will eventually heal and turn into scar tissue, it will often retract, The spinal cord will get used to the new position it is in and produce less pain
lumbar disk problems: exam
o Mechanical back pain with motion (in degenerative disk disease)
o May have blunted achilles tendon reflex (L5-S1) or patellar reflex (L3-4)
o May have positive straight leg raise on the affected side
o 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 (Indication for surgery)
o May have saddle anesthesia, reduced rectal tone and bowel/bladder incontinence in cases of cauda equina (a surgical emergency!)
lumbar disk problems: studies
o X-ray may show loss of disk space height in degenerative disk disease
o MRI is the study of choice for disk herniation. Most common at L4-5 or L5-S1, can be central or lateral, may look like a bulge in the disk or may be an extruded disk fragment
o On MRI, degeneration can sometimes be seen as modic changes at the vertebral endplats (inflammation associated with arthritis)
o For people who cant get MRI, the CT myelogram is the next best study to get (but is not as good as MRI)
lumbar disk problems: treatment
o Approximately 80% of disk herniation pain will resolve within six weeks. During that time, adise your patient to avoid heavy lifting and repetititve bending
o NSAIDS, oral prednisone, narcotics, muscle relaxants
o Nerve membrane stabilizers for nerve pain: gabapentin (Neurontin), pregabalin (Lyrica)
o Physical therapy can increase ROM and strengthen core muscles. Acupuncture may help with pain
o Corticosteroid epidural injections may provide relief of neurogenic pain (sciatica)
o Refer to spine surgeon for new onset or progressive weakness or incapacitation pain beyond 6 weeks (microdiscectomy for disk herniations or lumbar fusion for degenerative disk disease)
o If cauda equina is suspected, get a surgical evaluation right away
cervical disk problems
o Similar mechanism to lumbar disk problems. Although the cervical spine doesn’t bear weight like the lumbar spine does, it’s far mor mobile, and thus also prone to degeneration
cervical disk problems: history
o Neck pain, with or without HA
o Shooting arm pain (radiating “radicular” pain), or tingling down arm
o Numbness Iparesthesia) in fingers
o Progressive weakness unilaterally in specific muscle (deltoid, triceps, etc.) or loss of grip strength
o May have problems with balance, walking, or muscle spasms in legs
cervical disk problems: exam
o Loss of sensation in specific dermatome (know fingers C6, C7, C8) try to rule out carpal tunnel (Tinel’s sign), brachial plexopathy or ulnar neuropathy. An electromyogram may be indicated
o Positive spurling’s test for cervical radiculopathy. May also have neurogenic-type pain just medial to scalpula
o Always watch for signs of spinal cord compression as seen in cervical spinal stenosis (myelopathic gait, ankle clonus, hyperreflexia, Hoffman’s sign)
cervical disk problems: treatment
o NSAIDs, oral prednisone, narcotics, muscle relaxants. Gabapentin or pregabalin may be indicated for nerve pain
o Physical therapy to improve range of motion
o Short term use of soft cervical collar
o Refer to spine surgeon for incapacitating pain, declining motor function, or severe central stenosis
