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MBBS IV - Medical and Surgical Demonstration > O&T - Spine, Bone and Joints > Flashcards

O&T - Spine, Bone and Joints Flashcards

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USMLE® Step 1 flashcards
1
Q

D/dx Mechanical lower back pain

A

Mechanical (97%)

  • Back sprain (>70%)
  • Lumbar disc degeneration
  • Lumbar disc herniation
  • Spondylolisthesis
  • Fracture
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2
Q

D/dx Non-Mechanical lower back pain

A

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

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3
Q

3 common causes of LBP

A

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

Facet joint degeneration (back pain and referred pain)

Disc degeneration

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4
Q

Causes of acute. subacute and chronic LBP

A

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

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5
Q

Typical radiation of LBP

A

Lower back to to buttock and posterior thigh

Extension to below knee following dermatome = Nerve root involved

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6
Q

Quick way to differentiate mechanical or inflammatory cause of LBP

A

Mechanical - pain with movement, alleviated by rest

Inflammatory - pain at rest, alleviated by movement

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7
Q

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
A
  • 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
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8
Q

Aggravating and alleviating factors of spinal stenosis?

A

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

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

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9
Q

6 neurological symptoms associated with LBP

A 
Claudication 
Sciatica 
Numbness 
Weakness
Unsteady gait (think cervical/ thoracic stenosis + lumbar pathology)
Sphincter control (severe, advanced)
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10
Q

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

A
  • Under 20 or over 55
  • History of trauma, immunosuppression, malignancy
  • Neurological signs
  • Deformity
  • Night and rest pain
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11
Q

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?

A

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

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12
Q

Differentiate the listing posture of medial vs lateral disc herniation

A

Medial lesion = Listing towards lesion side

Lateral lesion = Listing away from lesion side

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13
Q

Which lumbar intervertebral space is the largest

A

Largest to smallest:

L4-5 > L5-S1 > L3-4

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14
Q

Imaging modalities for LBP associated neurological deficit

A

CT - Fracture only
CT myelogram
MRI - nerve compression

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15
Q

Discogenic back pain:
3 causes
Aggravating factors
2 radiological features

A

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
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16
Q

Explain why facet joint hypertrophy produces pain?

A

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

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17
Q

5 symptoms and signs for Cauda Equina syndrome

A

Caused by severe stenosis:

  • Acute LBP
  • Sciatica
  • Saddle parenthesia
  • LL weakness and gait dysfunction
  • Sphincter incontinenece
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18
Q

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

Name of condition?
Likely cause?

A

Neurogenic claudication

Nerve root compression e.g. by spinal canal narrowing

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19
Q

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

Likely spinal pathology?

A

Spondylolysis

20
Q

Typical symptom and signs of spondylolysis

Radiological features

A

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

21
Q

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

Likely spinal pathology?

A

Sacroiliac joint pain

22
Q 
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)

A

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

23
Q

Radiological features of Ankylosing spondylitis

A

X-ray:

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

Achilles tendon attachment at calcaneus show bone erosion

24
Q

6 common causes of neck pain

A 
Degenerative disc/ facet 
Nerve compression 
Cervical instability 
Soft tissue injury 
Inflammatory arthritis 
Neoplasm
25
Q

Test for radicular pain on the neck?

A

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

26
Q

Test for C3 cord compression associated with neck pain?

A

Scapulohumeral reflex

Tap on supraspinous tendon adjacent to acromion
POSITIVE = Upgoing deltoid contraction/ shrug

Indicates high cervical cord compression

27
Q

Test for C5-6 lesion causing radicular neck pain?

A

Inverted supinator reflex

procedure is the same as normal supinator reflex test

POSITIVE = loss of normal supinator reflex + abnormal flexion of fingers

28
Q

Test for C8 lesion.

A

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

29
Q

Test for cervical myelopathy (2)

A

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

30
Q

Differentiate the motor and sensory deficit in

  • Intraforaminal disc compression
  • Posterolateral disc compression
  • Midline disc compression
A
  • Intraforaminal disc compression = motor and sensory deficit
  • Posterolateral disc compression = mostly motor deficit
  • Midline disc compression = myelopathy
31
Q

2 causes of cervical spondylosis

A

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)

32
Q

Compare radiculopathy and myelopathy:

  • Cause
  • Progression
  • Frequency of pain
A

Radiculopathy:

  • Root compression
  • Dermatomal sensory deficit only
  • Self-limiting, usually never progress

Myelopathy:

  • Cord compression
  • LL motor deficit
  • only worsens. never better
33
Q

Causes of cervical radiculopathy?

Presentation?

A

Nerve root irritation by cervical disc rupture, osteophyte spurs

Sharp pain, tingling or burning sensation by dermatome

34
Q

Causes of cervical myelopathy? (5)

A

Cord compression by:

  • Protruding disc
  • Ossified posterior longitudinal ligament
  • Deformed uncovertebral process
  • Apophyseal joint
  • Ligamentum flavum hypertrophy

Grey matter more susceptible than white matter

35
Q

Cervical myelopathy symptoms

A 
Generalized fatigue 
Clumsiness of hands and weakness 
Loss of balance with gait disturbance 
Neck pain 
Bladder and bowel impairment
36
Q 
Generalized fatigue 
Clumsiness of hands and weakness 
Loss of balance with gait disturbance 
Neck pain*
Bladder and bowel impairment

Likely spinal pathology?

A

Cervical myelopathy

37
Q

2 common conditions associated with snake eye sign on MRI

A

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**

38
Q

3 principles of fracture treatment

A

Reduce if necessary
Immobilize if necessary
Rehabilitate always

39
Q

Define open and closed reduction of fracture

A

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

40
Q

Process of fracture reduction with soft tissue hinge

A

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

41
Q

Method to maintain reduction of the fracture

A

3 point fixation

  • Use soft tissue bridge under tension
  • Set plaster at tilted angle to maintain tension across broken joint to aid healing
42
Q

Composition of Plaster of Paris

A

Calcium sulphate or gypsum

43
Q

Define the 2 types of fracture fixation

A

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.

44
Q

Type of fracture fixation indicated for open and closed fractures?

A

Open fracture: High risk of infection, need EXTERNAL fixation

Closed fracture: Internal fixation

45
Q

Reduction and fixation for Intertrochanteric fracture of femur

A

open reduction and internal fixation

46
Q

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

A

open reduction and internal fixation

MBBS IV - Medical and Surgical Demonstration (17 decks)

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