MSK IV - Cervical and Lumbar Spine Flashcards
how many vertebra are there?
33
how many sacral vertebra?
5
how many coccyx vertebra?
4
how many cervical spinal nerves?
8
as start to go down vertebra, what happens to their size?
they get bigger - support more weight
what is a herniated disc?
it is a herniated nucleus pulposus from tear in the annulus fibrosus
at what level does the spinal cord end?
at L2
do intervertebral discs have their own blood supply? what do they depend on?
no
they depend on osmosis for nutrients in and waste out
who has a higher incidence of low back pain? why?
smokers - b/c smoking causes vasoconstriction causing discs to wear out sooner vs people that don’t smoke
what dermatome is at the nipple line?
T4
what dermatome is at the umbilicus?
T10
what does the AP cervical spine view of x-ray evaluate?
alignment of vertebrae, check for rotation
what does the lateral view for cervical spine evaluate?
vertebral alignment
what does the odontoid view for cervical spine assess?
used in trauma to assess C1-C2 clear space around the odontoid
what does the oblique view for cervical spine assess?
the facet joints for sponylolysis
what does the Fuchs view for cervical spine assess?
this is a modified odontoid
-shot through the soft tissue of the neck
what does the Swimmer’s view for cervical spine assess?
With arm close to cassette oriented upwards so C6-C7 can be visualized in larger sized person
what is an odontoid fracture aka?
peg or dens fracture
where does an odontoid fracture occur?
through dens (odontoid process) of C2
what is the most common upper cervical spine fracture?
odontoid fx
what is the mechanism of injury of odontoid fx’s?
can occur both during flexion or extension with or without compression
what are associated injuries of odontoid fx’s?
atlas fx (Jefferson fx)
transverse ligament rupture
pharyngeal injury
tx of atlas fx?
Halovest until the C-1 arch is healed -> then a posterior C1-C2 arthrodesis if the dens has not healed
what is prudent to obtain in all pts with a dens fx? especially when?
a CT scan of the C-spine
Especially if C1-C2 fusion is being considered
what makes dx of transverse ligament rupture?
MRI
non-operative tx of transverse ligament rupture results in?
atlantoaxial instability
what is a big concern of an odontoid fx?
retropulsion of fragments where bone goes back and dissects cord
REASON WHY WE NEED IMAGING
what is the conservative tx of odontoid fx?
halo brace for 3 months if:
- Initial dens displacement is <5 mm
- Reduction is maintained
- And patient is <50 years old
which pts heal well in halves for tx of odontoid fx?
- Age <65 years old
- Anterior displacement <5mm or posterior displacement <2 mm
- Diagnosis made within one week
what is the operative tx of odontoid fx?
Posterior atlantoaxial arthrodesis with wire and bone graft
procedure done for older people
what is cervical spondylosis?
combo of degenerative disc disease and osteophyte formation in cervical spine
what gender and at what age do people get cervical spondylosis?
age is 40-50 and men > women
where does cervical spondylosis most commonly occur?
at C5-C6 levels > C6-C7 levels
chronic cervical disc degeneration and facet arthropathy may lead to?
radiculopathy
what radiculopathy is most common in cervical spondylosis? second most common?
C7 = most common
followed by C6 radiculopathy radiation distally
what is radiculopathy?
radiation of numbness along course of spinal nerves
what is Grade 1 cervical spondylosis?
Minimal/early
- Minimal anterior osteophyte formation
- No reduction of intervertebral disc height
- No vertebral endplate sclerosis
what is Grade 2 cervical spondylosis?
Mild
- Definite anterior osteophyte formation
- Subtle or no reduction in intervertebral disc height (<25%)
- Just recognizable sclerosis of the endplates
what is Grade 3 cervical spondylosis?
Moderate
- Definite anterior osteophyte formation
- Moderate narrowing of the disc space (25-75%)
- Definite sclerosis of the endplates and osteophyte sclerosis
what is Grade 4 cervical spondylosis?
Gross
- Large and multiple large osteophyte formation is seen
- Severe narrowing of the disc space (>75%)
- Sclerosis of the endplates with irregularities
what is the most common symptoms of herniated nucleus pulposus of cervical spine?
other sx’s?
neck pain often with radiation of pain and/or numbness to arm
other sx’s:
- Extremity numbness
- Extremity weakness
what does herniated nucleus pulposus of cervical spine go hand in hand with?
degenerative disc disease (cervical spondylosis)
how do pts with herniated nucleus pulposus of cervical spine appear?
appear stiff/uncomfortable
what is the pain of herniated nucleus pulposus of cervical spine worse with?
flexion and extension of spine
what is a positive Spurling’s sign for herniated nucleus pulposus of cervical spine?
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
imaging for cervical spondylosis?
plain films and MRI
what do plain films assess for in herniated nucleus pulposus of cervical spine?
- Alignment -> spondylosis, lordosis
- Disc space narrowing
- Anatomical anomalies
what is the best method to assess level and morphology of herniation?
MRI
when do you do MRI for herniation?
if will be doing interventions (steroid injections, surgery)
tx for herniated disc - anywhere? (least invasive to most invasive)
pain control
oral steroids
PT
light activity
epidural steroid injections
surgery-disc excision (discectomy and fusion)
what oral steroids should NOT be used for herniated disc?
Medrol DosePak
what does PT tx involve for herniated disc?
U/S
E-stim
TENS - electrodes put over weak muscles to help stimulate them
is bed rest recommended for herniated disc?
NO!!! - want them up and moving!!!
indications for surgery-disc excision for herniated disc?
- Intractable pain
- Progressive neurological deficit
- Severe deltoid or wrist extensor weakness
- Myelopathy or pending myelopathy
what is the surgery for herniated cervical disc?
anterior cervical discectomy fusion (ACDF) - fusion of the vertebrae affected
what is a Hangman’s fx? mechanism?
a “judicial lesion”
Mechanism:
- Hyperextension and distraction mechanism
- Involved pars inter-articularis of C2 bilaterally
what is the MOST COMMON presentation of Hangman’s fx?
post-traumatic neck pain after high speed velocity hyperextension injury
most common association with Hangman’s fx?
high speed MVC
radiographic features of Hangman’s fx
Bilateral lamina and pedicle fracture at C2
Usually associated with anterolisthesis of C2 on C3
-Anterolisthesis = top vertebrae slips forward on bottom one
what should be ruled out for Hangman’s fx? why?
extension of fx to transverse foramina
-want to make sure there is no vertebral artery injury
if extension of Hangman’s fx to transverse foramina, what could be present?
vertebral artery injury
assessment for Hangman’s fx?
ABCs, maintain C-spine, TREAT OTHER INJURIES, early consult to spine/neuro
tx for Hangman’s fx?
hard collar initially, ORIF, halo brace
what is a Jefferson fx?
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
mechanism of Jefferson fx?
Axial loading along axis of cervical spine with occipital condyles being driven into lateral masses of C1
-aka diving head first into shallow end
is Jefferson fx associated with neurological deficit?
Not normally, but spinal cord injury can occur if there is retropulsed fragments
associated injuries of Jefferson fx?
other C-spine injuries, C2 fracture, vertebral artery injury, extra-cranial nerve injury
imaging for Jefferson fx?
X-ray, CT, MRI
what does X-ray of Jefferson fx show?
Asymmetry in odontoid view with displacement of lateral masses away from dens
Distance >6 mm suggests ligamentous injury
what does CT of Jefferson fx show?
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
is Jefferson fx seen better with MRI or CT?
CT
what is MRI of Jefferson fx used to view?
localized soft tissue injury/ligamentous injury
tx of Jefferson fx if no transverse Atlantal ligament injury?
conservative tx - hard collar immobilization
tx of Jefferson fx if there is transverse Atlantal ligament injury?
transverse Atlantal ligament injury is considered UNSTABLE
- halo immobilization
- posterior C1-C2 lateral mass internal fixation
- transoral internal fixation
what does AP view of lumbar spine do?
- Evaluate vertebral alignment
- Check rotation
what does lateral view of lumbar spine evaluate?
- Evaluate vertebral alignment
- Assess for subluxation or spondylolisthesis
what does Coned-down (Spot) view of lumbar spine evaluate?
Zooms in to L4 and L5 vertebrae -> most pathology will present here
where does most pathology of lumbar spine occur?
L4-L5
what is the most common cause of disability for pts under 45 y/o?
low back pain
if low back pain is sudden, what are you thinking?
lumbar disc herniation
when is nerve root impingement suspected with low back pain?
when pain is leg dominant
if there is pain in legs and goes past the knee, what are you thinking?
lumbar disc herniation
if pt with LBP is more comfortable standing, how do you do PE?
try to do most of PE with pt standing
save maneuvers most likely to cause for?
last
what is Waddell’s signs?
5 exam findings that correlated with NON-ORGANIC LBP (people look these up and pretend to have LBP)
what are the 5 Waddell’s signs?
(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
tx for low back pain?
pain control
PT
light activity
surgery
indications for surgery of LBP?
Cauda equina syndrome (only true orthopedic emergency)
HNP not responding to conservative treatment
Severe spinal deformity
what is the only TRUE orthopedic emergency?
Cauda equina syndrome
-nerve roots being pressed by a disc herniation
what lumbar spine levels are most affected by herniated disc?
L4-L5; L5-S1
sx’s of herniated lumbar disc?
pain with flexion or prolonged sitting
radicular pain with compression of nerves
extremity numbness/weakness
PE of lumbar herniated disc
LBP at level of affected disc (worse with activity)
Pain worse w/flexion/extension of spine
+SLR on affected side
contralateral +SLR is an indicator of?
severe disc herniation
what MUST be r/o if pt complains of perianal numbness of bladder/bowel incontinence?
Cauda equina syndrome
what does sciatica cause?
electric shock-like pain radiating down the posterior aspect of the leg -> often below the knee
why don’t you do MRIs for disc herniation unless going to do intervention?
b/c 40% will have some sort of abnormality even if that’s not what is causing their pain
what is spondylolysis?
Defect in pars interarticularis portion of neural arch that connects inferior and superior articular facets
Commonly known as pars defect
cause of spondylolysis?
repeated microtrauma resulting in stress fracture
also genetics is a factor
traumatic pars defects result from?
high energy trauma with hyperextension of lumbar spine
-football tackling sled and swimmers
where do MOST cases of spondylolysis occur? unilateral or bilateral?
L5 level (also at L4, but much less common)
can be unilateral or bilateral
sx’s of spondylolysis?
commonly asx’s
if symptomatic - have pain with extension and/or rotation of lumbar spine
what is a common cause of back pain in adolescents?
spondylolysis - esp in young athletes
imaging for spondylolysis?
oblique x-ray
-see “scotty dog” with a collar = fx thru the pars
if see scotty dog with a collar on x-ray what does that mean?
fx thru the pars of vertebrae
how do sx’s of spondylolysis usually resolve?
with non-operative care and activity limitation -> MOST TREATED CONSERVATIVELY
how long should pts with spondylolysis be treated conservatively?
at least 6-8 months
when is bracing a tx option for spondylolysis?
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
when is surgery indicated for tx of spondylolysis?
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
what is spondylolisthesis?
displacement of vertebral body in relation to inferior vertebra
where does spondylolisthesis most frequently occur?
at L5/S1 (much less commonly L4/L5)
can occur anywhere
what is anterolisthesis vs retrolisthesis?
anterolisthesis = anterior displacement of vertebral body relative to one below
retrolisthesis = posterior displacement of vertebral body relative to one below
what is spondylolisthesis often due to?
spondylolysis (pars interarticularis defects)
to adequately describe spondylolisthesis, what must be stated?
type
-anterolistehsis or retrolisthesis
grade (Meyerding Classification)
-grade 1-5
what does the Meyerding Classification do for spondylolisthesis?
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
what are the grades of spondylolisthesis?
Grade 1 - <25% displacement
Grade 2 - 25-50%
Grade 3 - 50-75%
Grade 4 - 75-100%
Grade 5 - spondyloptosis
what is spinal stenosis? seen in?
narrowing of spinal canal
seen in older/elderly pts
what is spinal stenosis caused by?
Osteoarthritis in lumbar spine
HNP compression of neural structures
Hypertrophy of Ligamentum Flavum
Congenital
sx’s of spinal stenosis?
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
what is the CLASSIC presentation of spinal stenosis?
Pain usually worse with back extension and relieved by leaning forward
what is better with standing, spinal stenosis or disc herniation?
disc herniation
what is better with sitting, spinal stenosis or disc herniation?
spinal stenosis
PE of spinal stenosis
limited extension of lumbar spine (may reproduce sx’s radiating down the legs)
+SLR on affected side (if + on contralateral side then means SEVERE)
what is the study of choice after x-rays for spinal stenosis?
MRI
if can’t get MRI for spinal stenosis, what do you get?
myelogram
tx of spinal stenosis?
pain control, PT, light activity, facet or epidural injections, surgery
what are the surgery options for spinal stenosis?
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
best tx option for spinal stenosis
surgery
what is a wedge fx? what aspect does it affect?
hyper flexion injury to the vertebral body resulting from axial loading
affects anterior aspect
wedge fx considered what?
a single-column stable fx
what is the MOST COMMON type of wedge fx?
thoracolumbar spine fx’s
causes of wedge fx’s?
insufficiency fx’s secondary to osteoporosis
can be secondary to focal bone lesion (ex: prostate cancer)
small portion d/t trauma
what will x-rays, CT, and MRI show for wedge fx’s?
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
what are compression fx’s? most common type?
osteoporotic fx’s that occur after fall from standing
most common type = vertebral compression fx
where do vertebral compression fx’s most commonly occur?
at midthoracic (T7-T8) spine and thoracolumbar junction (T12-L1)
osteoporotic spinal compression fx’s occur as a result of?
injury (fall on butt)
pressure from normal activities
long bones compression fx called?
oblique fx
vertebrae compression fx called?
wedge fx
radiographic findings of vertebrae compression fx’s?
Loss of height in anterior, middle, or posterior dimension of the vertebral body
vertebrae compression fx’s grading?
graded based on vertebral height loss:
- Mild -> 20-25%
- Moderate -> 25-40%
- Severe -> >40%
what does acute vertebrae compression fx look like on x-ray? chronic?
acute = signs indicate cortical breaking or impaction of trabeculae
chronic = absence of these signs
in uncertainty of acute or chronic compression fx, what do you look for on MRI?
MRI signs of edema (acute) and presence of radiotracer uptake on bone scintigraphy (acute) help decide fracture age
when do vertebral fx’s require tx?
when they are symptomatic
-pain/oss of mobility
nonsurgical tx of vertebral fx’s?
observation/bracing -> for old people
meds -> bisphosphonates for osteoporosis
surgical tx of vertebral fx’s?
Vertebroplasty
-provides pain relief and strengthening of the bone of vertebrae weakened by disease
indications for vertebroplasty for tx of vertebral fx’s?
- Insufficiency fracture
- Aggressive hemangioma
- Vertebral multiple myeloma
- Vertebral metastases
ABSOLUTE C/I’s for vertebroplasty tx of vertebral fx’s?
- Septicemia
- Active osteomyelitis of target vertebra
- Uncorrectable coagulopathy
- Allergy to bone cement or opacifying agent
RELATIVE C/I’s for vertebroplasty tx of vertebral fx’s?
- 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
complications of vertebroplasty tx of vertebral fx’s?
Leakage of vertebroplasty
- Compression of adjacent structures
- Inferior vena cava syndrome
Cement extravasation
- Extravasation into paravertebral veins
- Cement pulmonary embolism
