MSK/Rheumatology - Spinal Disorders - Exam 3 Flashcards
What are some of the risk factors for spinal disorders?
Poor physical conditioning, poor posture or body mechanics, occupational exposure, older age, obesity, pregnancy, and poor abdominal musculature
What XR views are essential in cervical trauma?
AP, Lateral, Odontoid, Swimmers view, and Oblique
What are the indications for lumbar XR?
Fall from height greater than 3 meters, fall from standing > 60 years or frail, MVA, Significant trauma, acute/severe back pain, history of CA, or neurological deficits
What XR view is used to visualize lumbar articular facets and pars interacrticularis?
Oblique
What XR view is used to visualize spinal stability and rule out spondylolisthesis?
Flexion-extension
What XR is used to visualize the alignment and look for infection, malignancy, fractures, and degenerative changes?
AP and lateral
What imaging is best for evaluating the spinal cord, nerve roots, meninges, disc abnormalities, or post op study?
CT myelogram (spinal canal is injected with contrast)
When are bone scans indicated?
For infectious or metastatic disease
What does Electromyography do?
Detects response of muscle to nerve stimulation
What does a nerve conduction study to?
It can determine specific site of nerve injury
What are the two types of neurophysiology studies?
Electromyography (EMG) or Nerve Conduction Study (NCS)
Which neurons are located in brainstem and corticospinal tracts of the spinal cord. They
initiate voluntary movement and maintains muscle tone.
Upper motor neurons
Which neurons are located in the spinal cord gray matter and the motor nuclei of cranial nerves. They stimulate skeletal muscle and produce movement.
Lower motor neurons
What is compression of or damage to the spinal cord which leads to tissue ischemia called? (upper motor neuron)
Myelopathy
What are the most common cause of myelopathy?
Spinal stenosis
What is a neurologic deficit related to the spinal nerve root called? (lower motor neuron)
Radiculopathy
What are the most common cause of radiculopathy?
Neuroforaminal narrowing
Does myelopathy or radiculopathy cause symptoms below the lesion?
Myelopathy
What is a shock-like sensation radiating into spine or arms with forward flexion of the neck called? What is it seen with?
Lhermitte sign
Myelopathy
Weakness, loss of sensation, increased muscle tone, hyperreflexia, up going plantar reflex, clonus, and muscle atrophy are often seen with what?
Myelopathy
Does Myelopathy or radiculopathy cause symptoms in a dermatomal pattern?
Radiculopathy
Hypotonia, hyporeflexia, areflexia, weakness, muscle atrophy, muscle fasciculation are often seen with what?
Radiculopathy
Strain indicates injury to what 3 things?
Muscle, tendon, and musculotendinous junction
A sprain indicates an injury to what?
Ligaments
What is the common cause of cervical strain/sprain?
Whiplash mechanism with rapid acceleration-deceleration causing rapid neck extension/flexion
What criteria is used for cervical sprain/strain imaging?
Nexus criteria
When are nexus rules not applicable?
- Direct blow to the neck
- Penetrating trauma to the neck
- Adults over 60 yo
What are the components of Nexus criteria and when is imaging not required?
- Absence of posterior midline tenderness
- Normal level of alertness
- No evidence of intoxication
- No Abnormal neurologic findings
- No other painful distracting injuries
If all 5 criteria are met, no imaging is needed
What should you do if patient does not meet all of the nexus criteria?
C-Spine must be cleared with imaging prior to assessing ROM or manipulation
On physical exam, a patient has paraspinous/trapezius muscle and sternocleidomastoid tenderness, Limited ROM of rotation of C-Spine, and a normal neuro exam. What are you suspicious of?
Cervical strain/sprain
What is the treatment for cervical strain/sprain?
- Short course of NSAIDs
- Short course of opioids for acute settings (no longer than 1-2 weeks)
- Soft cervical collar (not long term)
- Cervical pillows
- Avoid manipulation
What is the typical history in a patient that presents with a lumbar strain/sprain?
Acute onset of LBP often following a lifting episode or may be a minor event such as bending over
On physical exam, a patient has diffuse TTP in the low back/sacroiliac region, ROM of back is limited secondary to pain, muscle spasms, and a normal neuro exam. What are you suspicious of?
Lumbar strain/sprain
Patient presents with axial pain that radiates to buttocks and low back spasms. The patient cannot stand erect and has frequent positional changes.
What are you suspicious of?
Lumbar strain/sprain
What is the treatment of lumbar strain/sprain?
- Avoid strenuous activity, but NOT on bedrest
- NSAIDs
- Muscle relaxers generally not recommended
- PT, TENs unit, trigger point injection
- Core strengthening
What is Waddells sign and what other tests are used to support this finding?
- Non-organic behavior or an inappropriate finding based on patients symptoms.
- Stimulation sign, distraction sign, overreaction, and glove or stocking paresthesias
Using minimal axial compression or rotation to test for unusually severe pain.
What is sign is this?
Stimulation sign
Checking straight leg raise when patient is paying attention and then again when patient is distracted and comparing.
What sign is this?
Distraction sign
What is spondylosis?
“Spinal arthritis” often with osteophytes
- Nonspecific, degenerative changes of the spine affecting the discs, vertebral bodies and joints
What can spondylosis lead to?
Spinal stenosis and/or neuroforaminal narrowing
What is osteoarthritis of the intervertebral discs called?
Degenerative disc disease (DDD)
Patient presents with decreased ROM of the C-Spine, chronic neck pain, pain worse with upright activity, occipital HA, radicular symptoms, and myelopathy. What are you suspicious of?
Cervical spondylosis
On physical exam, a patient has TTP along the cervical paraspinal muscles an posterior spinous process, Decreased AROM, pain with facet loading, and a positive spurlings test. What are you suspicious of?
Cervical spondylosis
How do you perform spurlings test and what is a positive test?
-Extend and rotate neck to side of pain. Apply downward pressure on the head.
Positive test if patient experiences limb pain or paresthesias indicating nerve impingement
What imaging should be ordered for cervical spondylosis?
AP and lateral XRs.
MRI w and without contrast- allows for visualization of impingement and soft tissue inflammation
What is the treatment for cervical spondylosis?
- NSAIDs
- PT
- If significant, may require surgery
- Pain management referral
What is the hallmark symptom of lumbar spondylosis?
low back pain that radiates to one or both buttocks
A patient presents with low back pain radiating to their buttocks, decreased ROM, worsened pain with bending or lifting, pain relieved with laying down, and normal sensory/motor/ and DTRs. What are you suspicious of?
Lumbar spondylosis
What imaging should be ordered for lumbar spondylosis?
AP and lateral XRs to show osteophytes and disc narrowing
MRI if warranted
What is the treatment for lumbar spondylosis?
- NSAIDs
- PT
- If facet arthritis, consider referral to interventional pain management
What is spondylolisthesis?
Anterior displacement of a vertebra body, commonly in the L-Spine
Patient presents with pain that radiates to shoulders, pain with ROM, decreased ROM, and occipital headaches. What are you suspicious of?
Cervical spondylolisthesis
Patient presents with back pain that radiates posteriorly to below the knees that is worse with standing. They also complain of spasms in the hamstrings that make it difficult to bend forward.
What are you suspicious of?
Lumbar spondylolisthesis
What imaging should be ordered for spondylolisthesis?
Lateral XRs to visualize forward translation of vertebrae.
Interval XRs every 6 months to evaluate further slippage.
-Oblique view for isolated spondylosis
What is the treatment for spondylolisthesis?
- Referral to ortho for neurosurgery
- May require surgical fixation
What is Spondylolysis and who is it commonly seen in?
Unilateral or bilateral defect in the vertebral pars interarticularis, commonly an overuse or stress fracture
-Seen in adolescents with repetitive forced back extension.
Where is Spondylolysis seen about 90% of the time?
L5
What is a “Scotty Dog Fracture”?
Defect in the pars interarticularis
What is the treatment of Spondylolysis?
Bracing, PT, restriction of activity
What commonly causes radiculopathy in young patients?
Older patients?
Young: lifting and twisting activities can increased spinal pressure resulting in herniation of the IV disc
Older: Degenerative changes can tear the annulus with disc prolapse and can press on nerve root
Spinal cord compression can lead to ***.
Myelopathy
Where is radiculopathy most commonly in the lumbar spine?
L4-L5 and L5-S1
Where is radiculopathy most commonly in the cervical spine?
C6-C7
A patient presents radicular pain in the upper extremities following a nerve root distribution that is unilateral. Patient has weakness and reduced grip strength on that side. Patient has neck pain and headache. What are you suspicious of?
Cervical radiculopathy
Patient has pain starting in the neck, radiating down in the arm, and going into the thumb. What Dermatome is this?
C6
Patient has pain starting in the neck, traveling down the posterior arm, and going into the 2nd and 3rd fingers. What dermatome is this?
C7
Patient has pain that starts in his neck, travels down the medial aspect of his arm, and goes into his 4th and 5th fingers. What dermatome is this?
C8
Patient has pain that travels down the lateral aspect of the thigh, the anterior aspect of the leg, the bottom of the foot, and into the 1st, 2nd, 3rd, and 4th toes. What dermatome is this?
L5
Patient has pain that travels down the anterior aspect of the thigh, the anterior and medial aspect of the leg, and the 1st toe. What dermatome is this?
L4
Patient has pain traveling down the posterior aspect of the thigh and leg, lateral lower leg, and into the 5th toe. What dermatome is this?
S1
Patient has pain traveling down the posterior aspect of the thigh and leg and the medial plantar foot. What dermatome is this?
S2
If an impingement occurs between L1 and L4, where is the patient likely to have pain?
Anterior thigh
If an impingement occurs from L4 and below, where is the patient likely to have pain?
Radiating down to the foot
A patient presents with acute low back pain that radiating from the buttocks/thigh into the foot. Laying on their back with their knees elevated or in fetal position relieves their pain. What condition are you suspicious of?
Lumbar radiculopathy
What two physical exam findings should be present in someone with cervical radiculopathy?
Decreased cervical ROM and loss of cervical lordosis
What physical exam findings should be present in someone with lumbar radiculopathy?
- Positive straight leg test (symptom reproduction)
- Reverse straight leg raise for lesions above L4
- LBP and spasms
How do you perform a reverse straight leg raise and what is a positive test?
-Patient lies prone. Lift the hip into extension while keeping the knee straight.
Pain over the anterior thigh suggests an upper lumbar disc problem
When should an MRI be ordered for radiculopathy?
If symptoms persist over 4 weeks, or if there is significant neurologic deficit or myelopathy is identified
What is the treatment for a patient with clear radicular symptoms and nonprogressive neurologic deficits?
NSAIDs, Corticosteroids, and PT
What is the treatment for a patient with confirmed radiculopathy and severe pain or worsening neurologic deficits?
Epidural injections
-Surgical referral with no improvement or worsening of symptoms or with concern for myelopathy
What are the congenital forms for spinal stenosis?
Dwarfism, congenitally small spinal canal, and Spina bifida
What is the most common form of acquired spinal stenosis?
Spondylosis
What is the most common cause of neurogenic leg pain in the elderly?
Lumbar spinal stenosis
What is neurogenic claudication?
Progressive bilateral leg pain aggravated by standing or walking
A patient presents with neurogenic claudication that is relieved by leaning forward and laying supine for 15-30 minutes. They have radicular symptoms without back pain. What condition are you suspicious of?
Lumbar spinal stenosis
When a patient presents with claudication, what must you differentiate between?
Neurogenic vs vascular leg pain with walking
Patient has a cramping/tight leg pain that is increased with waking, and relieved when standing erect. Not relieved when walking flexed with a cart. Patient has immediate relief when sitting or laying down. Pain is increased when walking uphill and downhill. Which form of claudication do you suspect?
Vascular
Patient has pain/numbness/tinging to their leg that is increased when walking, but relieved when walking flexed with a cart. Pain is not relieved when standing erect. Pain is relieved in minutes when sitting/laying down. Pain is not increased when walking uphill, but does increase when walking downhill. What form of claudication do you suspect?
Neurogenic
What is the most common cause of myelopathy in the elderly?
Cervical spinal stenosis
What is cervical spinal stenosis typically caused by?
Progressive spondylosis with osteophyte formation, disc herniation, and ligamentous flavum hypertrophy
Patient presents with pain is neck that radiates to arms. Patient has numbness in their arms with weakness, sensory deficits, and a gait disturbance. What condition do you suspect?
Cervical spinal stenosis
What are the common causes of lumbar spinal stenosis?
Spondylosis, ligamentous flavum hypertrophy, HNP, and spinal cord compression
What imaging should be ordered for cervical and lumbar stenosis?
AP/lateral XRs for good initial info.
MRI is TEST OF CHOICE, preferred over CT.
CT myelogram good, but invasive.
EMS/NCS if unclear etiology or to rule out unclear diagnosis
What is the recommended treatment for spinal stenosis?
- NSAIDs
- Cervical brace and activity restriction
- PT for core strengthening for lumbar stenosis
- epidural steroid injections
- surgical decompression for fusion if significant stenosis
What is cauda equina syndrome?
- Surgical emergency!
- Compression of lumbar, sacral, coccygeal nerve roots
What are the causes of cauda equina?
Intervertebral disc herniation, epidural abscess, tumor, lumbar spinal stenosis, metastatic disease, infection, and autoimmune
Patient presents with LBP that radiates to legs with leg weakness in multiple distributions. Patient has weak plantar flexion and loss of ankle reflex. Positive saddle anesthesia, urinary incontinence, decreased anal sphincter tone, and sexual dysfunction. What condition are you suspicious of?
Cauda Equina
What is the treatment for Cauda Equina?
- Dexamethasone 10mg IV x1 immediately
- Emergent MRI w/ contrast
What other area of pain is thoracic pain commonly associated with?
Chest pain
What are some of the causes of thoracic pain?
Trauma, muscle strain, spondylosis, spondylolisthesis, and thoracic disc herniation
What are these red flags for?
Unexplained weight loss, no improvement with treatment, duration of pain greater than 1 month, pain at night, hx of CA, older than 50 yo.
Malignancy
What are these red flags for?
Pain at rest, back pain with fever, immunocompromised, IVDA, and recent history of infection
Infection
What is compression of the UE neurovascular bundle above the first rib and behind the clavicle called?
Thoracic outlet syndrome
What are some of the causes of thoracic outlet syndrome?
Respective injury or athletic arm movements, cervical rib anomaly, muscular anomalies, injury/trauma
What are the 3 types of thoracic outlet syndrome and what kind of compression is each?
1) neurogenic -Brachial plexus compression
2) Arterial- Subclavian artery compression
3) Venous- subclavian vein compression
A Patient presents with reproducible pain with elevation of arm with weakness/numbness. Patient has progressive unilateral weakness to the hypothenar muscle, numbness over ulnar and medial nerve distribution, and tenderness of the scalene muscle. What form of thoracic outlet syndrome are you suspicious of?
Neurogenic thoracic outlet syndrome
What is the most common form of thoracic outlet syndrome?
Neurogenic
What is arterial thoracic outlet syndrome almost always associated with?
Cervical rib fracture
A young patient presents with a thromboembolism to their hand. They have pain, paresthesias, pallor, and coolness to that arm and the pulses at the wrist are diminished. What form of thoracic outlet syndrome are you concerned about?
Arterial thoracic outlet syndrome
What is the hallmark sign of venous thoracic outlet syndrome?
Swelling to the extremity
What is venous thoracic outlet syndrome commonly repeated to?
Vigorous, repetitive UE activities
A patient presents with swelling to one of their extremities with paresthesias, cyanosis, pain, and fatigue to the arm. What form of thoracic outlet syndrome are you concerned about?
Venous thoracic outlet syndrome
What testing should you order to diagnose neurogenic thoracic outlet syndrome?
Electrodiagnostic testing, brachial plexus block, CT angiography, and MRI
What tests should you order to diagnose arterial and vein thoracic outlet syndrome?
US (initial image) CXR (If no cervical rib, can almost definitely rule out aTOS), CT angiography, and MRI
What is the treatment for nTOS?
- PT for 4-6 weeks
- Steroid injections, botulinum toxin type A
- Decompression surgery for worsening symptoms
What is the treatment for vTOS?
- Catheter directed thrombolysis (best within 2 weeks of symptom onset)
- Decompressive surgery
What is the treatment for aTOS?
- Surgical embolectomy
- Decompressive surgery
