Midterm - New week 1 Flashcards
First step in differential diagnosis of NMS condition
Injury or diease
3 spinal causes of musculoskeletal pain from disease
- Metastatic/primary tumor
- Infection
- Inflammatory disease (AS, RA, etc)
2 non-spinal causes of musculoskeletal pain from disease
- Viscerosomatic
2. Other: AAA, endocrine
___% of LBP is due to serious disease. ___% due to local cancer or spinal infection. ___% due to referred pain from GI, reproductive or urinary
3%
1
2
History is ___% of diagnosis
90
Excruciating pain when lying supine, relived by sitting up, hunched over a table suggests
Malignant retroperitoneal lymphadenopathy
spinal percussion is exquisite and lingers with what three conditions. Give sensitivity and specificity of each
- cancer (poor Sn and sp)
- fracture (poor Sn and sp)
- spinal infection (86% Sn, 60% sp)
At least __/__ of bone cancers are metastatic. Usually from (4 things)
2/3
- breast, lung, prostate, kidney
Most metastatic bone cancers are osteo______. A few are osteo______ like _____
Osteolytic
Osteoblastic (like prostate cancer)
What is Lefebvre’s 20-50 rule. What is normal range
If <20mm/hr abnormal but probably not clinically meaningful
If >50m/hr probably significant disease process requiring further testing and advanced imaging
Normal range is 0-18 mm/hr
ESR>100 think what 3 thing
- multiple myeloma
- temporal arteritis
- polymyalgia rheumatica
Increased white count (>11,500) can suggest ________immature white cells can suggest _______.
Depressed suggest _______
- spinal infection, cancer or inflammatory disease
- Leukemia
- Multiple myeloma or other cancers
Two most common causes of elevated calcium
- Metastatic cancer
- hyperparathyroidism
AP increases in osteo_____ cancer to >____. Normal = ______.
What should you think when you see >AP
Osteoblastic
>150
0-50
Paget’s disease
What three places do viscerosomatic and LBP originate
Reproductive
Urinary
Gastrointestinal
What is a pathognomic sign
Strongly indicates a certain disease
Ex: thoracolumbar pain relieved by knees drawn up and forward flexion is pathognomic of a pancreas issue
Where does the colon (except sigmoid) refer
Mid-lumbar spine
Where do gynecological disorders refer
Above L4
Where do sigmoid colon, rectum and pelvic refer
Sacral
What are the 5 diagnostic possibilities of leg and back pain?
Nerve involvement - myelopathy - radiculopathy - neuropathy No nerve involvement - deep referred pain - Separate lesions
What are characteristics of sclerotogenous pain
- deep-aching, diffuse pain
- sclerotomal segmetnal patterns
- Often more proximal than distal (does not go beyond the knee)
- pain often radiates over time (referral territory grows)
- field may skip regions
What is the most common type of spine related extremity pain seen in practice?
Sclerotogenous pain
When the patient has leg or arm symptoms with spinal pain, one of the top priorities is to
Decide with if symptoms are neuropathic or not
What are the 5 steps of neuropathic assessment
History
- leg pain (location? quality? Severity? Spine position)
- paresthesia
Physical exam
- nerve tension tests
- sensory, motor, reflex tests
- spinal loading
Once you find there is nerve damage, what is the next step
Find out what part of the nervous system
What are the 4 main leg pain qualities of radicular syndrome?
1. Location may be past the knee, may be dermatomal, feels superficial (skin deep) 2. Quality Sharp, stabbing, electrical, painful cold, lancinating 3. Severity leg pain often worse than back pain 4. Spinal position Sometimes affected by spine position
What is the paresthesia of radicular syndrome
Often present and more likely to follow a dermatomal distribution
What is the sensory, motor, reflex of radicular syndrome?
Ma be one or more deficits usually corresponding to the same nerve root (may be hypersensitivity instead)
What two things may cause nerve root compression
Herniated disc
Spinal stenosis
What are the results of nerve tension tests in radicular syndrome
often reproduce leg symptoms
Nerve tension tests (SLR, XSLR, Braggard, Bowstring, Bonnet, Slump, Dreyerle) provoke and inflamed peripheral nerve (aka ________) or it’s nerve roots (aka ________)
Neuritis
Radiculitis
SLR tensions what nerve roots and peripheral nerve?
what is a hard and soft positive test?
L4, L5, S1
Sciatic nerve
Hard- create or aggravates lower extremity pain below knee
Soft - above knee
SLR is good at testing for patients with ______ but has a poorer sensitivity for What additional 3?
Posterolateral disc herniations
- spinal stenosis
- spondylolisthesis (sensitivity 14%)
- midline and medial disc herniations
What is braggard test?
Patient supine, leg raised, dorsiflex foot
What is bowstring test
Patient supine, knee flexed, apply pressure to tibial nerve in popliteal fossa
What is bonnet test
Patient supine, leg raised, internally rotate and adduct hip
What is maximum SLR test
Dorsiflex, internally rotate, chin on chest, bear down
What is the Bechetrew test
Seated SLR
What is slump test
Seated maximum SLR
Seated SLR, foot dorsiflexed, leg internally rotated, with spine “slumped”, bearing down
What nerve roots and peripheral nerve is the femoral stretch test.
L2, L3, L4
Femoral nerve
What are spinal loading (kemps, valsalva, flexion) results of radicular syndrome
Rapid reproduction of leg symptoms
If there are neuropathic findings what is the next step
- find which nerve root is involved
- is it irritated, soft neurologic sign, hard sign
- what is the cause
Once you have enough clues a nerve root is damaged, call it a radicular finding. If it has no defects, call it _______. If it has even one defect, call it _______
Radiculitis
Radiculopathy
what is Alcock’s syndrome
Pudendal nerve lesion
*the back probably will not hurt.
What are three reasons of peripheral nerve entrapment and compression?
- piriformis syndrome
- perineal nerve compression
- femoral neuropathy secondary to pelvic tumor
What are three peripheral nervous system diseases
- diabetes
-alcohol neuropathy
Vitamin B12 deficiency
What is the leg pain neuropathic tool for peripheral nerve
Follow a peripheral nerve territory (stocking distribution)
- often burning, may be stabbing, electrical, sharp
Not likely to be affected by spine position
What is the leg paresthesia neuropathic tool of peripheral nerve?
Usually present and in a peripheral nerve territory (stocking distribution)
What is the SMR neuropathic tool of peripheral nerve
May be one or more deficits usually corresponding to the same peripheral nerve
What is the nerve tension test neuropathic tool of peripheral nerve?
Often reproduce leg symptoms
What is the spinal loading procedure of neuropathic tool of peripheral nerve
Usually do not reproduce leg symptoms
What nerve roots make the femoral nerve
L2-4
What are three causes of femoral neuropathy
- diabetic mononeuropathy
- Tumor
- Psoas or iliacus hematoma
What motor symptoms might be seen with femoral nerve damage
Hip flexors and knee extensors affected first. First sign may be knee buckling
- week iliopsoas and quadratus muscle testing. Single leg raise form chair
- if there is also adductor weakness, the lesion is NOT the femoral nerve but more proximal (lumbosacral plexus or L2-4)
Which reflex is associated with femoral nerve? Which stretch test?
Patellar reflex
Femoral stretch test - creates sharp anterior thigh pain
T/F there is motor involvement with Meralgia Paresthetica
FALSE
What age tends to get Meralgia paresthetica?
40-60
What is one of the most common neuropathies
Peroneal nerve entrapment from crossing legs while sitting
What might be characteristic of perineal nerve entrapment
- foot drop may be partial or complete (often primary presentation)
- weak ankle dorsiflexion, great toe extension or eversion
- numbness/paresthesia over lateral aspect of lower leg and dorsum of foot
Forced ankle inversion may increase pain because it stretches the nerve
T/F cord problems are not commonly associated with low back pain
T
What are three injuries that could cause cord compression? What disease?
- TLJ compression fracture
- upper lumbar disc lesion
- spinal canal stenosis
- diabetes
T/F both CES and spinal cord compression symptoms include urinary incontinence, constipation and impotence
T
What are 5 pathologies associated with a positive Romberg’s test?
1 - myelopathy
2- peripheral nerve lesion (eg. diabetic neuropathy)
3- multiple nerve lesions (eg. due to spinal stenosis)
4- cerebellar disease
5 - vestibular disorders
What is the leg pain neuropathic tool for lumbar myelopathy?
- May or may not be present
- Location: Generalized, sometimes soles of feet (not dermatomal)
- Quality: Often described as burning
- Severity: Usually back pain is worse than leg pain
What is the leg paresthesia neuropathic tool of myelopathy?
May be present but not dermatomal, often a sense of numbness
What is the SMR neuropathic tool of myelopathy?
May have some sensory loss (contralateral pain, ipsilateral position sense/vibration/two point discrimination), may have UMNL signs, may have +Romberg/balance tests)
What would the nerve tension test neuropathic tool show for myelopathy
Negative
What would spinal loading neuropathic tool for myelopathy show
Symptoms not affected by spinal loading
How do you make a diagnosis of deep referred pain?
Exclude neuropathic pain. This is based primarily on negative results
What is the leg pain neuropathic tool of deep referred pain
Usually not past the knee (but definitely can be)
Location: More general, non-dermatomal
Quality: achy, crampy, grabbing (many possible descriptors)
Severity: Back pain usually > than leg pain Sometimes affected by prolonged spine position
What is the leg paresthesia neuropathic tool of deep referred pain
Not usually present, but when present it is non dermatomal
What is the SMR neuropathic tool for deep referred pain show
Usually no deficits
What does the nerve tension tests neuropathic tool for deep referred pain show
Usually negative (may aggravate LBP)
What does spinal loading neuropathic tool for deep referred pain show?
Usually do not reproduce leg symptoms
Burning pain and dynamic tactile allodynia is associated with ______
Peripheral neuropathic pain, not radicular
esthesia
Perception of sensation
Paresthesia
Sense on pins and needles, tingling, itching
Odd sensations not needed to be provoked by physical exam
Dysesthesia
Distorted unpleasant sensations perceived in response to normally non-noxious stimuli
Allodynia
Nonnoxious stimuli perceived as painful
Hypesthesia
(Hypoesthesia) decreased sensitivity to touch
Hyperesthesia
Increased sensitivity to touch
Anesthesia
Absence of touch sensation
Analgesia
Absence of pain sensation
Hypoalgesia
Decreased sensitivity to pain
Hyperalgesia
Increased sensitivity to pain
