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Clin Med 4 > MSK IV - Cervical and Lumbar Spine > Flashcards

MSK IV - Cervical and Lumbar Spine Flashcards

1
Q

how many vertebra are there?

A

33

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2
Q

how many sacral vertebra?

A

5

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3
Q

how many coccyx vertebra?

A

4

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4
Q

how many cervical spinal nerves?

A

8

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5
Q

as start to go down vertebra, what happens to their size?

A

they get bigger - support more weight

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6
Q

what is a herniated disc?

A

it is a herniated nucleus pulposus from tear in the annulus fibrosus

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7
Q

at what level does the spinal cord end?

A

at L2

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8
Q

do intervertebral discs have their own blood supply? what do they depend on?

A

no

they depend on osmosis for nutrients in and waste out

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9
Q

who has a higher incidence of low back pain? why?

A

smokers - b/c smoking causes vasoconstriction causing discs to wear out sooner vs people that don’t smoke

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10
Q

what dermatome is at the nipple line?

A

T4

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11
Q

what dermatome is at the umbilicus?

A

T10

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12
Q

what does the AP cervical spine view of x-ray evaluate?

A

alignment of vertebrae, check for rotation

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13
Q

what does the lateral view for cervical spine evaluate?

A

vertebral alignment

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14
Q

what does the odontoid view for cervical spine assess?

A

used in trauma to assess C1-C2 clear space around the odontoid

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15
Q

what does the oblique view for cervical spine assess?

A

the facet joints for sponylolysis

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16
Q

what does the Fuchs view for cervical spine assess?

A

this is a modified odontoid

-shot through the soft tissue of the neck

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17
Q

what does the Swimmer’s view for cervical spine assess?

A

With arm close to cassette oriented upwards so C6-C7 can be visualized in larger sized person

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18
Q

what is an odontoid fracture aka?

A

peg or dens fracture

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19
Q

where does an odontoid fracture occur?

A

through dens (odontoid process) of C2

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20
Q

what is the most common upper cervical spine fracture?

A

odontoid fx

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21
Q

what is the mechanism of injury of odontoid fx’s?

A

can occur both during flexion or extension with or without compression

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22
Q

what are associated injuries of odontoid fx’s?

A

atlas fx (Jefferson fx)

transverse ligament rupture

pharyngeal injury

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23
Q

tx of atlas fx?

A

Halovest until the C-1 arch is healed -> then a posterior C1-C2 arthrodesis if the dens has not healed

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24
Q

what is prudent to obtain in all pts with a dens fx? especially when?

A

a CT scan of the C-spine

Especially if C1-C2 fusion is being considered

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25
Q

what makes dx of transverse ligament rupture?

A

MRI

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26
Q

non-operative tx of transverse ligament rupture results in?

A

atlantoaxial instability

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27
Q

what is a big concern of an odontoid fx?

A

retropulsion of fragments where bone goes back and dissects cord

REASON WHY WE NEED IMAGING

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28
Q

what is the conservative tx of odontoid fx?

A

halo brace for 3 months if:

  • Initial dens displacement is <5 mm
  • Reduction is maintained
  • And patient is <50 years old
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29
Q

which pts heal well in halves for tx of odontoid fx?

A
  • Age <65 years old
  • Anterior displacement <5mm or posterior displacement <2 mm
  • Diagnosis made within one week
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30
Q

what is the operative tx of odontoid fx?

A

Posterior atlantoaxial arthrodesis with wire and bone graft

procedure done for older people

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31
Q

what is cervical spondylosis?

A

combo of degenerative disc disease and osteophyte formation in cervical spine

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32
Q

what gender and at what age do people get cervical spondylosis?

A

age is 40-50 and men > women

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33
Q

where does cervical spondylosis most commonly occur?

A

at C5-C6 levels > C6-C7 levels

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34
Q

chronic cervical disc degeneration and facet arthropathy may lead to?

A

radiculopathy

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35
Q

what radiculopathy is most common in cervical spondylosis? second most common?

A

C7 = most common

followed by C6 radiculopathy radiation distally

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36
Q

what is radiculopathy?

A

radiation of numbness along course of spinal nerves

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37
Q

what is Grade 1 cervical spondylosis?

A

Minimal/early

  • Minimal anterior osteophyte formation
  • No reduction of intervertebral disc height
  • No vertebral endplate sclerosis
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38
Q

what is Grade 2 cervical spondylosis?

A

Mild

  • Definite anterior osteophyte formation
  • Subtle or no reduction in intervertebral disc height (<25%)
  • Just recognizable sclerosis of the endplates
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39
Q

what is Grade 3 cervical spondylosis?

A

Moderate

  • Definite anterior osteophyte formation
  • Moderate narrowing of the disc space (25-75%)
  • Definite sclerosis of the endplates and osteophyte sclerosis
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40
Q

what is Grade 4 cervical spondylosis?

A

Gross

  • Large and multiple large osteophyte formation is seen
  • Severe narrowing of the disc space (>75%)
  • Sclerosis of the endplates with irregularities
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41
Q

what is the most common symptoms of herniated nucleus pulposus of cervical spine?

other sx’s?

A

neck pain often with radiation of pain and/or numbness to arm

other sx’s:

  • Extremity numbness
  • Extremity weakness
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42
Q

what does herniated nucleus pulposus of cervical spine go hand in hand with?

A

degenerative disc disease (cervical spondylosis)

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43
Q

how do pts with herniated nucleus pulposus of cervical spine appear?

A

appear stiff/uncomfortable

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44
Q

what is the pain of herniated nucleus pulposus of cervical spine worse with?

A

flexion and extension of spine

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45
Q

what is a positive Spurling’s sign for herniated nucleus pulposus of cervical spine?

A

Sit them down, turn their head to the side a little and press down -> if there is pain or a return of sensation then its positive

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46
Q

imaging for cervical spondylosis?

A

plain films and MRI

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47
Q

what do plain films assess for in herniated nucleus pulposus of cervical spine?

A
  • Alignment -> spondylosis, lordosis
  • Disc space narrowing
  • Anatomical anomalies
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48
Q

what is the best method to assess level and morphology of herniation?

A

MRI

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49
Q

when do you do MRI for herniation?

A

if will be doing interventions (steroid injections, surgery)

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50
Q

tx for herniated disc - anywhere? (least invasive to most invasive)

A

pain control

oral steroids

PT

light activity

epidural steroid injections

surgery-disc excision (discectomy and fusion)

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51
Q

what oral steroids should NOT be used for herniated disc?

A

Medrol DosePak

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52
Q

what does PT tx involve for herniated disc?

A

U/S

E-stim

TENS - electrodes put over weak muscles to help stimulate them

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53
Q

is bed rest recommended for herniated disc?

A

NO!!! - want them up and moving!!!

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54
Q

indications for surgery-disc excision for herniated disc?

A
  • Intractable pain
  • Progressive neurological deficit
  • Severe deltoid or wrist extensor weakness
  • Myelopathy or pending myelopathy
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55
Q

what is the surgery for herniated cervical disc?

A

anterior cervical discectomy fusion (ACDF) - fusion of the vertebrae affected

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56
Q

what is a Hangman’s fx? mechanism?

A

a “judicial lesion”

Mechanism:

  • Hyperextension and distraction mechanism
  • Involved pars inter-articularis of C2 bilaterally
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57
Q

what is the MOST COMMON presentation of Hangman’s fx?

A

post-traumatic neck pain after high speed velocity hyperextension injury

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58
Q

most common association with Hangman’s fx?

A

high speed MVC

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59
Q

radiographic features of Hangman’s fx

A

Bilateral lamina and pedicle fracture at C2

Usually associated with anterolisthesis of C2 on C3
-Anterolisthesis = top vertebrae slips forward on bottom one

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60
Q

what should be ruled out for Hangman’s fx? why?

A

extension of fx to transverse foramina

-want to make sure there is no vertebral artery injury

61
Q

if extension of Hangman’s fx to transverse foramina, what could be present?

A

vertebral artery injury

62
Q

assessment for Hangman’s fx?

A

ABCs, maintain C-spine, TREAT OTHER INJURIES, early consult to spine/neuro

63
Q

tx for Hangman’s fx?

A

hard collar initially, ORIF, halo brace

64
Q

what is a Jefferson fx?

A

burst fx of C1 (atlas)

Originally defined as 4-part fracture with double fractures through anterior and posterior arches

Now 3-part and 2-part fractures as well

65
Q

mechanism of Jefferson fx?

A

Axial loading along axis of cervical spine with occipital condyles being driven into lateral masses of C1

-aka diving head first into shallow end

66
Q

is Jefferson fx associated with neurological deficit?

A

Not normally, but spinal cord injury can occur if there is retropulsed fragments

67
Q

associated injuries of Jefferson fx?

A

other C-spine injuries, C2 fracture, vertebral artery injury, extra-cranial nerve injury

68
Q

imaging for Jefferson fx?

A

X-ray, CT, MRI

69
Q

what does X-ray of Jefferson fx show?

A

Asymmetry in odontoid view with displacement of lateral masses away from dens

Distance >6 mm suggests ligamentous injury

70
Q

what does CT of Jefferson fx show?

A

shows fracture line usually involving both anterior/posterior arches

If injury to transverse atlantal ligament -> atlantodental interval increases (ADI)
-ADI = distance between anterior arch of the atlas and the dens of the axis

71
Q

is Jefferson fx seen better with MRI or CT?

A

CT

72
Q

what is MRI of Jefferson fx used to view?

A

localized soft tissue injury/ligamentous injury

73
Q

tx of Jefferson fx if no transverse Atlantal ligament injury?

A

conservative tx - hard collar immobilization

74
Q

tx of Jefferson fx if there is transverse Atlantal ligament injury?

A

transverse Atlantal ligament injury is considered UNSTABLE

  • halo immobilization
  • posterior C1-C2 lateral mass internal fixation
  • transoral internal fixation
75
Q

what does AP view of lumbar spine do?

A
  • Evaluate vertebral alignment

- Check rotation

76
Q

what does lateral view of lumbar spine evaluate?

A
  • Evaluate vertebral alignment

- Assess for subluxation or spondylolisthesis

77
Q

what does Coned-down (Spot) view of lumbar spine evaluate?

A

Zooms in to L4 and L5 vertebrae -> most pathology will present here

78
Q

where does most pathology of lumbar spine occur?

A

L4-L5

79
Q

what is the most common cause of disability for pts under 45 y/o?

A

low back pain

80
Q

if low back pain is sudden, what are you thinking?

A

lumbar disc herniation

81
Q

when is nerve root impingement suspected with low back pain?

A

when pain is leg dominant

82
Q

if there is pain in legs and goes past the knee, what are you thinking?

A

lumbar disc herniation

83
Q

if pt with LBP is more comfortable standing, how do you do PE?

A

try to do most of PE with pt standing

84
Q

save maneuvers most likely to cause for?

A

last

85
Q

what is Waddell’s signs?

A

5 exam findings that correlated with NON-ORGANIC LBP (people look these up and pretend to have LBP)

86
Q

what are the 5 Waddell’s signs?

A

(1) Tenderness
- superficial pain with light touch to skin
- deep pain

(2) Simulation
- pain with light axial compression on skull
- pain with light twisting of pelvis

(3) Distraction - no pain with distracted SLR
(4) Regional - non anatomic or inconsistent motor/sensory findings during entire exam
(5) Over-reaction - any time during exam

87
Q

tx for low back pain?

A

pain control
PT
light activity
surgery

88
Q

indications for surgery of LBP?

A

Cauda equina syndrome (only true orthopedic emergency)

HNP not responding to conservative treatment

Severe spinal deformity

89
Q

what is the only TRUE orthopedic emergency?

A

Cauda equina syndrome

-nerve roots being pressed by a disc herniation

90
Q

what lumbar spine levels are most affected by herniated disc?

A

L4-L5; L5-S1

91
Q

sx’s of herniated lumbar disc?

A

pain with flexion or prolonged sitting

radicular pain with compression of nerves

extremity numbness/weakness

92
Q

PE of lumbar herniated disc

A

LBP at level of affected disc (worse with activity)

Pain worse w/flexion/extension of spine

+SLR on affected side

93
Q

contralateral +SLR is an indicator of?

A

severe disc herniation

94
Q

what MUST be r/o if pt complains of perianal numbness of bladder/bowel incontinence?

A

Cauda equina syndrome

95
Q

what does sciatica cause?

A

electric shock-like pain radiating down the posterior aspect of the leg -> often below the knee

96
Q

why don’t you do MRIs for disc herniation unless going to do intervention?

A

b/c 40% will have some sort of abnormality even if that’s not what is causing their pain

97
Q

what is spondylolysis?

A

Defect in pars interarticularis portion of neural arch that connects inferior and superior articular facets

Commonly known as pars defect

98
Q

cause of spondylolysis?

A

repeated microtrauma resulting in stress fracture

also genetics is a factor

99
Q

traumatic pars defects result from?

A

high energy trauma with hyperextension of lumbar spine

-football tackling sled and swimmers

100
Q

where do MOST cases of spondylolysis occur? unilateral or bilateral?

A

L5 level (also at L4, but much less common)

can be unilateral or bilateral

101
Q

sx’s of spondylolysis?

A

commonly asx’s

if symptomatic - have pain with extension and/or rotation of lumbar spine

102
Q

what is a common cause of back pain in adolescents?

A

spondylolysis - esp in young athletes

103
Q

imaging for spondylolysis?

A

oblique x-ray

-see “scotty dog” with a collar = fx thru the pars

104
Q

if see scotty dog with a collar on x-ray what does that mean?

A

fx thru the pars of vertebrae

105
Q

how do sx’s of spondylolysis usually resolve?

A

with non-operative care and activity limitation -> MOST TREATED CONSERVATIVELY

106
Q

how long should pts with spondylolysis be treated conservatively?

A

at least 6-8 months

107
Q

when is bracing a tx option for spondylolysis?

A

If symptoms persist despite activity modification

Pts with painful spondylolysis, but no slip í treated by bracing for 6-8 months and then gradual brace removal

108
Q

when is surgery indicated for tx of spondylolysis?

A

Painful spondylolysis not responding to orthosis after 6-8 months

If L5 pars defect -> an L5-S1 arthrodesis should be done (fusion)

Decompression required only for focal neurologic deficit
-Not for leg pain only

109
Q

what is spondylolisthesis?

A

displacement of vertebral body in relation to inferior vertebra

110
Q

where does spondylolisthesis most frequently occur?

A

at L5/S1 (much less commonly L4/L5)

can occur anywhere

111
Q

what is anterolisthesis vs retrolisthesis?

A

anterolisthesis = anterior displacement of vertebral body relative to one below

retrolisthesis = posterior displacement of vertebral body relative to one below

112
Q

what is spondylolisthesis often due to?

A

spondylolysis (pars interarticularis defects)

113
Q

to adequately describe spondylolisthesis, what must be stated?

A

type
-anterolistehsis or retrolisthesis

grade (Meyerding Classification)
-grade 1-5

114
Q

what does the Meyerding Classification do for spondylolisthesis?

A

Grading system for spondylolisthesis

Divides the superior endplate of the vertebra below into 4 quarters
-grade depends on the location of the posteroinferior corner of the vertebra above

115
Q

what are the grades of spondylolisthesis?

A

Grade 1 - <25% displacement

Grade 2 - 25-50%

Grade 3 - 50-75%

Grade 4 - 75-100%

Grade 5 - spondyloptosis

116
Q

what is spinal stenosis? seen in?

A

narrowing of spinal canal

seen in older/elderly pts

117
Q

what is spinal stenosis caused by?

A

Osteoarthritis in lumbar spine

HNP compression of neural structures

Hypertrophy of Ligamentum Flavum

Congenital

118
Q

sx’s of spinal stenosis?

A

Pain which worsens with extension

Reproducible single or bilateral leg symptoms worse after walking several minutes

Relieved by sitting (as opposed to disc which is better when standing)

Pain usually worse with back extension and relieved by leaning forward -> CLASSIC

119
Q

what is the CLASSIC presentation of spinal stenosis?

A

Pain usually worse with back extension and relieved by leaning forward

120
Q

what is better with standing, spinal stenosis or disc herniation?

A

disc herniation

121
Q

what is better with sitting, spinal stenosis or disc herniation?

A

spinal stenosis

122
Q

PE of spinal stenosis

A

limited extension of lumbar spine (may reproduce sx’s radiating down the legs)

+SLR on affected side (if + on contralateral side then means SEVERE)

123
Q

what is the study of choice after x-rays for spinal stenosis?

A

MRI

124
Q

if can’t get MRI for spinal stenosis, what do you get?

A

myelogram

125
Q

tx of spinal stenosis?

A

pain control, PT, light activity, facet or epidural injections, surgery

126
Q

what are the surgery options for spinal stenosis?

A

Spinal decompression
-widening the spinal canal or laminectomy

Nerve root decompression
-freeing a single nerve

Spinal fusion
-joining the vertebra to eliminate motion and diminish pain from arthritic joints

127
Q

best tx option for spinal stenosis

A

surgery

128
Q

what is a wedge fx? what aspect does it affect?

A

hyper flexion injury to the vertebral body resulting from axial loading

affects anterior aspect

129
Q

wedge fx considered what?

A

a single-column stable fx

130
Q

what is the MOST COMMON type of wedge fx?

A

thoracolumbar spine fx’s

131
Q

causes of wedge fx’s?

A

insufficiency fx’s secondary to osteoporosis

can be secondary to focal bone lesion (ex: prostate cancer)

small portion d/t trauma

132
Q

what will x-rays, CT, and MRI show for wedge fx’s?

A

Cortical disruption with impaction of the antero-superior endplate

Antero-inferior endplate and posterior vertebral body remain unaffected

The result is the characteristic “wedged” appearance

133
Q

what are compression fx’s? most common type?

A

osteoporotic fx’s that occur after fall from standing

most common type = vertebral compression fx

134
Q

where do vertebral compression fx’s most commonly occur?

A

at midthoracic (T7-T8) spine and thoracolumbar junction (T12-L1)

135
Q

osteoporotic spinal compression fx’s occur as a result of?

A

injury (fall on butt)

pressure from normal activities

136
Q

long bones compression fx called?

A

oblique fx

137
Q

vertebrae compression fx called?

A

wedge fx

138
Q

radiographic findings of vertebrae compression fx’s?

A

Loss of height in anterior, middle, or posterior dimension of the vertebral body

139
Q

vertebrae compression fx’s grading?

A

graded based on vertebral height loss:

  • Mild -> 20-25%
  • Moderate -> 25-40%
  • Severe -> >40%
140
Q

what does acute vertebrae compression fx look like on x-ray? chronic?

A

acute = signs indicate cortical breaking or impaction of trabeculae

chronic = absence of these signs

141
Q

in uncertainty of acute or chronic compression fx, what do you look for on MRI?

A

MRI signs of edema (acute) and presence of radiotracer uptake on bone scintigraphy (acute) help decide fracture age

142
Q

when do vertebral fx’s require tx?

A

when they are symptomatic

-pain/oss of mobility

143
Q

nonsurgical tx of vertebral fx’s?

A

observation/bracing -> for old people

meds -> bisphosphonates for osteoporosis

144
Q

surgical tx of vertebral fx’s?

A

Vertebroplasty

-provides pain relief and strengthening of the bone of vertebrae weakened by disease

145
Q

indications for vertebroplasty for tx of vertebral fx’s?

A
  • Insufficiency fracture
  • Aggressive hemangioma
  • Vertebral multiple myeloma
  • Vertebral metastases
146
Q

ABSOLUTE C/I’s for vertebroplasty tx of vertebral fx’s?

A
  • Septicemia
  • Active osteomyelitis of target vertebra
  • Uncorrectable coagulopathy
  • Allergy to bone cement or opacifying agent
147
Q

RELATIVE C/I’s for vertebroplasty tx of vertebral fx’s?

A
  • Radiculopathy caused by a compressive syndrome unrelated to vertebral collapse
  • Retropulsion of fracture fragment or epidural tumor extension causing signs and symptoms of neurological compromise
  • Current systemic infection
  • Patient improving on medical therapy
  • Prophylaxis in osteoporotic patients
  • Myelopathy or cauda equina syndrome originating at fracture level
148
Q

complications of vertebroplasty tx of vertebral fx’s?

A

Leakage of vertebroplasty

  • Compression of adjacent structures
  • Inferior vena cava syndrome

Cement extravasation

  • Extravasation into paravertebral veins
  • Cement pulmonary embolism

Clin Med 4 (11 decks)

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