Neck and back (2Q)

Question 1

Ankylosing spondylitis: patient

Answer 1

M>F; usually early adulthood (but can occur in 16-juvinile form)

Question 2

Ankylosing spondylitis: Sx

Answer 2

Insidious onset, begins as pain in buttocks, heels, and lower back. Typically worse in morning, improves with activity, worse in evening.

Question 3

Ankylosing spondylitis: Px

Answer 3

Enthesitis, loss of lordosis, reduced spinal ROM. Uveitis (30%); chest tightness (30%)

Question 4

Ankylosing spondylitis: Imaging

Answer 4

Sacroiliac joints show symmetric, bilateral widening followed by subchondrial erosions and ankylosis. Vertebra are ‘squared’ losing anterior concavity and syndesmophytes form especially in vertebral margins. Usually begins in lumbar spine.

Question 5

Ankylosing spondylitis: labs (diagnosis and progress)

Answer 5

RF negative; HLA B27 positive (88-96%); Creatinine phosphokinase (CPK) is a good indicator of disease severity.

Question 6

Ankylosing spondylitis: treatment

Answer 6

Early: Indomethacin and exercises. About 10% of patients require surgery (remove v-shape, refuse in fixed position) due to fixed bony flexion of spine, loss of horizontal gaze, or ambulatory problems.

Question 7

Cervical spondylosis: patient

Answer 7

Men>50; Women>60, esp w/ hx of degenerative disc disease.

Question 8

Cervical spondylosis: pathogenesis

Answer 8

Disc degeneration–> loss of water and proteoglycans–> degeneration of longitudinal ligaments w/ bony spur formation–> disc space narrowing–> buckling of ligmentum flavum–> narrowing of spinal canal–> cord/artery impingement

Question 9

cervical spondylosis: Sx

Answer 9

occipital headache, worse in morning improving throughout day, painful or stiff neck. May be accompanied by radiculopathy, usually this is paresthesias of arm, and rarely pain (parasthesias distal, pain proximal).

Question 10

cervical spondylosis: Px

Answer 10

Decreased ROM in neck, radiculopathy with sensory and motor deficits may occur (Sensory before motor). Cervical spondylotic myelopathy (severe complication) has signs of upper motor neuron lesion.

Question 11

cervical spondylosis: imaging

Answer 11

plain film or MRI signs of narrowing of spinal canal (less than 10-13 mm between C3 and C7) measured between an osteophyte on inferior aspect of vertebral body and the base of the spinous process of the vertebra below.

Question 12

cervical spondylosis: Tx

Answer 12

Initial management: soft collar (until sx subside), anti-inflammatorys, PT w/ mild traction (except in cord compression, RA, or osteoarthritis). Analgesics and muscle relaxants are also helpful.

Epidural corticosteroids help with radiculopathy, and trigger point injections help with pain.

Surgery (disc decompression) if the patient does not respond to a conservative treatment protocol or shows evidence of deteriorating myelopathy or radiculopathy.

Question 13

disc herniation: patient

Answer 13

patient is typically over 40 and may have occupational history of strain or be obese.

Question 14

disc herniation sx:

Answer 14

Classically present with low back pain that acutely changes to radiating leg pain (which eclipses the back pain). Pt. may also have numbness or weakness in pattern of compressed nerve root.

Sx are worse with flexion and sitting, and improved with extension (standing, lying down) and may be exacerbated by full extension at knee.

Question 15

disc herniation: Px

Answer 15

Check L1-S1 dermatomes for light touch and pinprick (may have assymmetry).
Gait abnormalities/difficulty bearing weight on ipsilateral leg.

Straight leg raise (SLR): pt supine, elevate leg 20-70 degrees and reproduce radiating pain (in same or contralateral leg). Prone SLR eliciting anterior thigh pain with extension of leg suggests L2-L4 level herniation.

Question 16

disc herniation: imaging

Answer 16

MRI showing protrusion (bulge of posterior disk), extrusion (mushroom-like), or sequestration (complication of extrusion in which nerniated nucleus pulpus is no longer in continuity w/ disc of origin).

Protrusion= most common, MUST correlate to clinical findings, worst surgical prognosis
Extrusion=  more diagnositic, better prognosis.

Question 17

disc herniation: Tx

Answer 17

Conservative: PT/exercise, activity modification, NSAIDs, narcotics, muscle relaxers, steroids (sx resolve 60-90%)
Surgery: decompression of nerve root by removal of offending disc fragment.

Question 18

Indications for surgery in disc herniation:

Answer 18

1. persistent sx despite nonoperative tx
2. profound or progressive motor deficit
3. cauda equina syndrome
4. intractable pain
5. patient preference

Question 19

spinal stenosis: patient

Answer 19

Pt. may have Hx of disc degeneration, herniation, or osteophytes. Pt w/ congenitally narrow spinal canal will present in adolescence. Most pts >50.

Question 20

spinal stenosis: Sx

Answer 20

insidious onset radiating buttock and leg pain that is exacerbated by extension (standing, walking downhill) and improved by flexion (sitting, fetal position). Opposite of disc herniation. There can be associated numbness, weakness, or easy fatigue of legs. Radiculopathy may be present even at rest.

Question 21

spinal stenosis: Px

Answer 21

No conclusive signs, r/o osteoarthritis, other causes

Question 22

spinal stenosis: imaging

Answer 22

non-contrast MRI to find narrowing.

Question 23

spinal stenosis: tx

Answer 23

symptomatic (same as disc herniation). Surgical for persistent or non-remitting pain- decompressive laminectomy of stenotic areas.

Question 24

degenerative disk disease: patient

Answer 24

more common in older, obese patients

Question 25

degenerative disk disease: Sx

Answer 25

insidious onset low-back pain exacerbated by flexion and improved with extension (like herniated disk). Pain may radiate to buttocks, thigh, or groin (but rarely below knee w/o nerve involvement).
Pain that does not improve with rest has a poor surgical prognosis.

Question 26

degenerative disc disease: Px

Answer 26

Nothing specific, just back pain that is worse with flexion and not accompanied by neurologic sx.

Question 27

degenerative disc disease: imaging

Answer 27

Xray (upright!): disk space narrowing, vertebral body osteophytes.

MRI T2 is diagnostic for showing disc degeneration.

Note: the vast majority of people with radiologic findings of degenerative disks do NOT have symptoms and therefore do not have DDD!

Question 28

DDD: Tx

Answer 28

no excellent treatments: same as for spinal stenosis and disk herniation (symptomatic). DDD that is refractory to 6 mo of nonoperative therapy may benefit from surgery.

Surgery= spinal fusion and stabilization. Note that 1/3 of DDD patients are refractory to ALL treatment.

Question 29

spondylolisthesis: definition

Answer 29

abnormal slippage of one vertebra over the next.

Question 30

degenerative spondylolisthesis: patient

Answer 30

typically pts are >50

Question 31

spondylolisthesis: Sx

Answer 31

low back or leg pain with radicular symptoms like spinal stenosis (can actually cause spinal stenosis). L4/5 is most common. Isthmic type may have “clunking” sensation on flexion and extension.

Question 32

isthmic spondylolisthesis: patient

Answer 32

10-30s. L5/S1 is most common.

Question 33

spondylolisthesis: imaging

Answer 33

easily visualized on xray, especially standing lateral. Lateral listhesis can also occur and requires AP or MRI/CT to visualize.

Question 34

spondylolisthesis: tx

Answer 34

Adults w/ isthmic or degenerative slips rarely progress. Not operative Tx is same as for all back pain. Surgery is recommended for pts who choose it or are refractory to medical Tx.

Children and iatrogenic slips often WILL progress and should undergo surgical fusion.