O&T - Spine, Bone and Joints

Question 1

D/dx Mechanical lower back pain

Answer 1

Mechanical (97%)

• Back sprain (>70%)
• Lumbar disc degeneration
• Lumbar disc herniation
• Spondylolisthesis
• Fracture

Question 2

D/dx Non-Mechanical lower back pain

Answer 2

Neoplasia
Inflammatory arthritis
Infection
Non-spinal causes (PID, endometriosis, pyelonephritis…etc)

Question 3

3 common causes of LBP

Answer 3

Myofascial sprain (heal in 4 weeks, young, active)

Facet joint degeneration (back pain and referred pain)

Disc degeneration

Question 4

Causes of acute. subacute and chronic LBP

Answer 4

Acute: fracture, infection
Subacute: tumor, infection
Chronic: degeneration, claudication, spinal stenosis, facet joint hypertrophy

Question 5

Typical radiation of LBP

Answer 5

Lower back to to buttock and posterior thigh

Extension to below knee following dermatome = Nerve root involved

Question 6

Quick way to differentiate mechanical or inflammatory cause of LBP

Answer 6

Mechanical - pain with movement, alleviated by rest

Inflammatory - pain at rest, alleviated by movement

Question 7

Causes of pain based on aggravating factors:’

• Heavy exertion, repetitive bending, twisting and heavy lifting
• Pain on lumbar Flexion
• Pain on extension or rotation or lateral flexion

Answer 7

• Heavy exertion, repetitive bending, twisting and heavy lifting = Simple mechanical backpain
• Pain on lumbar Flexion = Disc Herniation
• Pain on extension or rotation or lateral flexion = Facet joint hypertrophy

Question 8

Aggravating and alleviating factors of spinal stenosis?

Answer 8

Aggravating:
Spine extension, Standing or walking - nerve compression from spinal canal narrowing

Alleviating:
Rest, spine flexion - increase spinal canal and formina size

Question 9

6 neurological symptoms associated with LBP

Answer 9

Claudication 
Sciatica 
Numbness 
Weakness
Unsteady gait (think cervical/ thoracic stenosis + lumbar pathology)
Sphincter control (severe, advanced)

Question 10

Red flag sings for spine fracture, tumor, infection, inflammatory disease or Cauda Equina syndrome?

Answer 10

• Under 20 or over 55
• History of trauma, immunosuppression, malignancy
• Neurological signs
• Deformity
• Night and rest pain

Question 11

Patient presentation:

25/m
Sudden back pain and right leg pain after weight lifting
Bedridden
Dx with lumbar disc herniation

Expected physical symptoms?
Additional tests to confirm dx?

Answer 11

Listing to the left
Tense lower back muscle
Loss of lumbar lordosis
Lumbar flexion limited

Straight leg raise: Stretch sciatic nerve to confirm radiculopathy
Lasegue test: dorsiflex ankle of extended leg to confirm radiculopathy

Question 12

Differentiate the listing posture of medial vs lateral disc herniation

Answer 12

Medial lesion = Listing towards lesion side

Lateral lesion = Listing away from lesion side

Question 13

Which lumbar intervertebral space is the largest

Answer 13

Largest to smallest:

L4-5 > L5-S1 > L3-4

Question 14

Imaging modalities for LBP associated neurological deficit

Answer 14

CT - Fracture only
CT myelogram
MRI - nerve compression

Question 15

Discogenic back pain:
3 causes
Aggravating factors
2 radiological features

Answer 15

Causes:

• Biomechanical
• Inflammatory - cytokine release
• Annular tear and ingrowing of nerve and vasculature to disc

Aggravate by:
- Forward flexion posture

Radiological:

• High intensity zone
• Disc bulging anterior and posteriorly
• Posterior annulus fissure

Question 16

Explain why facet joint hypertrophy produces pain?

Answer 16

Synovial membrane and capsule of facet joint is innervated by dorsal rami from 2 spinal levels

Question 17

5 symptoms and signs for Cauda Equina syndrome

Answer 17

Caused by severe stenosis:

• Acute LBP
• Sciatica
• Saddle parenthesia
• LL weakness and gait dysfunction
• Sphincter incontinenece

Question 18

Walking increases severity of burning/ aching pain and numbness with weakness

Name of condition?
Likely cause?

Answer 18

Neurogenic claudication

Nerve root compression e.g. by spinal canal narrowing

Question 19

LBP with insidious onset
Radiculopathy
Hamstring spasm and fixed hip and knee flexion
Flattened lordosis

Likely spinal pathology?

Answer 19

Spondylolysis

Question 20

Typical symptom and signs of spondylolysis

Radiological features

Answer 20

LBP with insidious onset
Radiculopathy
Hamstring spasm and fixed hip and knee flexion
Flattened lordosis

SPECT: Increased nucleotide uptake (stress reaction)
X-ray: Vertebral body slippage - posterior spinal alignment kinking

Question 21

Pain localized lateral to sacral spine.
Radiates to buttock.
Radiologically normal, no disc herniation.

Likely spinal pathology?

Answer 21

Sacroiliac joint pain

Question 22

Onset of back pain at early adulthood/ young  
Insidious onset 
Morning stiffness 
Persistent 
Associated with HLA-B27 

Likely spinal pathology?
Further test to confirm? (3)

Answer 22

Ankylosing spondylitis

1) Occiput-to-wall test: stand straight with back against wall and measure distance from occipital prominence to wall
2) Chest expansion test: ankylosis of thoracic spine = limited chest expansion
3) Schober test: Mark 10cm above midpoint between 2 PSIS, ask patient to flex, measure increase in distance between mid-PSIS to mark. >5cm is normal

Question 23

Radiological features of Ankylosing spondylitis

Answer 23

X-ray:

bamboo spine, syndesmophyte formation and vertebral body fusion, sacroiliac joint fusion

Achilles tendon attachment at calcaneus show bone erosion

Question 24

6 common causes of neck pain

Answer 24

Degenerative disc/ facet 
Nerve compression 
Cervical instability 
Soft tissue injury 
Inflammatory arthritis 
Neoplasm

Question 25

Test for radicular pain on the neck?

Answer 25

Spurling test Lateral extension of neck to one side + put axial compression on the head = cause narrowing of nerve root foramen POSITIVE =pain arising in the neck radiates in the direction of the corresponding dermatome ipsilaterally

Question 26

Test for C3 cord compression associated with neck pain?

Answer 26

Scapulohumeral reflex Tap on supraspinous tendon adjacent to acromion POSITIVE = Upgoing deltoid contraction/ shrug Indicates high cervical cord compression

Question 27

Test for C5-6 lesion causing radicular neck pain?

Answer 27

Inverted supinator reflex procedure is the same as normal supinator reflex test POSITIVE = loss of normal supinator reflex + abnormal flexion of fingers

Question 28

Test for C8 lesion.

Answer 28

Hoffman's sign - Involuntary finger flexion from disinhibition of C8 reflex Flick distal phalanx of middle whilst stabilizing interphalangeal joint POSITIVE = other fingers also flex

Question 29

Test for cervical myelopathy (2)

Answer 29

1) 10 second test: grip and release more than 20 times in 10 seconds POSITIVE = unable to flex and extend all fingers at the same time 2) Finger escape sign: unable to assume adduction or full extension of fingers

Question 30

Differentiate the motor and sensory deficit in - Intraforaminal disc compression - Posterolateral disc compression - Midline disc compression

Answer 30

- Intraforaminal disc compression = motor and sensory deficit - Posterolateral disc compression = mostly motor deficit - Midline disc compression = myelopathy

Question 31

2 causes of cervical spondylosis

Answer 31

1) Degenerative disc collapse > uncovertebral joints contact and facet joints hypertrophy > Osteophytes cause nerve compression 2) Facet arthrosis (caused by articular cartilage degeneration, inflammation, osteophyte...etc)

Question 32

Compare radiculopathy and myelopathy: - Cause - Progression - Frequency of pain

Answer 32

Radiculopathy: - Root compression - Dermatomal sensory deficit only - Self-limiting, usually never progress Myelopathy: - Cord compression - LL motor deficit - only worsens. never better

Question 33

Causes of cervical radiculopathy? | Presentation?

Answer 33

Nerve root irritation by cervical disc rupture, osteophyte spurs Sharp pain, tingling or burning sensation by dermatome

Question 34

Causes of cervical myelopathy? (5)

Answer 34

Cord compression by: - Protruding disc - Ossified posterior longitudinal ligament - Deformed uncovertebral process - Apophyseal joint - Ligamentum flavum hypertrophy Grey matter more susceptible than white matter

Question 35

Cervical myelopathy symptoms

Answer 35

``` Generalized fatigue Clumsiness of hands and weakness Loss of balance with gait disturbance Neck pain Bladder and bowel impairment ```

Question 36

``` Generalized fatigue Clumsiness of hands and weakness Loss of balance with gait disturbance Neck pain* Bladder and bowel impairment ``` Likely spinal pathology?

Answer 36

Cervical myelopathy

Question 37

2 common conditions associated with snake eye sign on MRI

Answer 37

Snake eye appearance of spinal cord: bilaterally symmetric circular to ovoid foci of high T2-weighted signals in the anterior horn cells of the spinal cord 1) spinal cord infarction affecting the anterior spinal artery ** 2) chronic compressive myelopathy**

Question 38

3 principles of fracture treatment

Answer 38

Reduce if necessary Immobilize if necessary Rehabilitate always

Question 39

Define open and closed reduction of fracture

Answer 39

Open reduction is where the fracture fragments are exposed surgically by dissecting the tissues = open wound Closed reduction is the manipulation of the bone fragments without surgical exposure of the fragments = closed, internal wound

Question 40

Process of fracture reduction with soft tissue hinge

Answer 40

Traction Exaggerate angulation of fracture to relax soft tissue hinge Put the soft tissue hinge back into tension

Question 41

Method to maintain reduction of the fracture

Answer 41

3 point fixation - Use soft tissue bridge under tension - Set plaster at tilted angle to maintain tension across broken joint to aid healing

Question 42

Composition of Plaster of Paris

Answer 42

Calcium sulphate or gypsum

Question 43

Define the 2 types of fracture fixation

Answer 43

Internal: Involves the use of devices internally (under the skin) positioned within the patient's body. External: The devices are screwed into fractured bones to exit the skin and are attached to a stabilizing structure outside the body.

Question 44

Type of fracture fixation indicated for open and closed fractures?

Answer 44

Open fracture: High risk of infection, need EXTERNAL fixation Closed fracture: Internal fixation

Question 45

Reduction and fixation for Intertrochanteric fracture of femur

Answer 45

open reduction and internal fixation

Question 46

comminuted intra-articular fracture of the distal end of the radius Reduction and fixation

Answer 46

open reduction and internal fixation