ortho- spine Flashcards
what does IPROMST stand for?
inspection, palpation, ROM, special tests
___% of US adult pop is disabled due to LBP (low back pain)
1-2%
*and makes up 1/3 of all disability costs
neck/arm pain- degenerative process begins in what decade? what about symptoms?
degenerative process begins in 3rd (30s) decade. Symptoms common in aged 40-60
initial Dx of neck + arm pain: imaging
Xray
initial Dx of neck + arm pain: activity or rest?
Activity modification, not bed rest!! - bed rest is about the WORST thing you can do
what % of neck/arm pain get better with conservative measures? what are these?
75%
analgesiscs, NSAIDs, muscle relaxants (sedating)
steroids- epidural or oral
PT, heat + ice, massage
4 signs further eval needed with neck/arm pain
- Continued severe arm pain for 10+ days without benefit from conservative txt
- Chronic relapsing arm pain
- Significant weakness that does not resolve with therapy
- Signs of cord compression - Myelopathy
how can cervical spine give a similar presentation to rotator cuff injury?
Cervical nerve roots C4-6 innervate the rotator cuff muscles
Sensory distribution runs from base of neck to outer edge of shoulder. Any of these nerves can produce pain in the scapula, shoulder, upper / lower arm, hand
***NEED meticulous PE to determine which is which
most common location of radiculopathy, cause?
Most common location C5, C6, C7: Due to increased motion
what is radiculopathy?
radiculopathy- means youre pushing on the nerve roots
weakness WITH pain
weakness without pain is likely NOT radiculopathy
painless weakness is common or rare?
rare
acute cervical disc protrusions: two types
lateral and central herniations
lateral disc herniation can cause what?
motor, sensory, or reflex changes in a radicular (usually C6 or C7) distribution on affected side
Leads to pain in the neck and radicular pain in the arm, exacerbated by head movement
central disc herniations can cause what?
spinal cord may be involved
significant CNS dysfunction-Spastic paresis, sensory disturbances, impaired sphincter function
Dx of an acute cervical disc protrusion is confirmed what two possible ways?
confirmed by MRI or CT myelogram
what is spurling’s test?
Foraminal compression - test cervical nerve root irritability -Standing behind the patient, head is bent backwards and flexed laterally to the symptomatic side.
This posture may elicit pain or paresthesia in the involved root.
- positive: pain recreated
= Dx cervical radiculopathy (herniated disc)
4 tests for rotator cuff /impingement (provocative tests)
Neer’s
Hawkins’
Jobe’s (empty can)
Drop arm
clinical symptoms of rotator cuff injury (4)
Pain with Abduction
Pain with lowering a fully raised arm
Atrophy of shoulder muscles
Weakness with arm rotation
clinical symptoms of cervical radiculopathy (3)
Reduction in pain with arm Abduction (decreases nerve root tension)
Sensory changes along dermatome
Small percentage will have painless weakness
what imaging would you do for rotator cuff tear vs cervical radiculopathy? (5) which is the best?
Xray (AP + lateral) MRI (BEST) Myelogram (2nd best) CT (last choice) Bone scan: malignancy/infection
most common initial symptoms of spinal cord compression (3)
Usually lower limbs – dragging or shuffling
Clumsiness of hands and fingers
Difficulty intitiating micturition (urinating)
what is the pain and neurodeficit like with spinal cord compression? (kinds weeds)
Central pain - Diffuse, dull, aching, burning
Involving limbs or side of trunk
Flex/Ext cause electric shock pain or tingling
Neurologic deficit
Progressive weakness
Sensory disturbance
Sphincter disturbance
is spinal cord compression dangerous?
a neuro emergency!!!
Dx imaging for spinal cord compression
MRI
while MRI is great at imaging soft tissue structures, eval of shoulder girdle, disc herniation, metastasis, tumor infections… what is it NOT good at imaging
Limited in the evaluation of fusion and hardware placement
what is CT imaging good for? (3) what is it the best tool for?
- evaluating the osseous anatomy in multiple planes
- presence of osseous fusion in post surgical patients
- Evaluation of hardware
* **Best tool for evaluating the osseous anatomy in multiple planes
* fast and available
downfall of CT
ionization radiation exposure
what is myelography ?
Radiologist injects iodinated contrast material into thecal sac
Multiple X-rays taken often with patient standing and in extension and flexion
*CT scan performed after injection
when is myelography used?
when pt can’t have MRI
cervical spondylosis: what is it? (4 parts)
Chronic disk degeneration–> Herniation–> Secondary calcification
1+ nerve roots impinged from herniations or osteophytic outgrowths
*myelopathy may develop
symptoms of cervical spondylosis
Neck pain, decreased ROM
Occipital HA
Radicular pain
Sensory or motor deficits
Most common type of spinal cord dysfunction in patients > 55 years
spondylosis w/ myelopathy
signs of sondylosis w/ myelopathy - in order of when they show up (3)
- gait spasticity
- upper-extremity numbness and loss of fine motor control in the hands
- late sign bladder dysfunction
recommended txt for spondylosis w/ myelopathy
conservative treatment is NOT indicated (unlike most degenerative conditions of the back)
- recommended: surgery relatively early (within 1 year of symptom onset)
symptoms of spondylosis w/ myelopathy
- Pain in the neck, subscapular area, or shoulder
- Anesthesias or paresthesias in the upper extremities
- Sensory changes in the lower extremities
- Motor weakness in the upper or lower extremities
- Gait difficulties
what is needle EMG (electromyelography) useful for? (neck pain) (weeds)
Needle EMG can detect acute, subacute, and chronic radicular features if motor nerve fiber pathology exists.
NCS(nerve conduction study) /EMG : differentiating cervical radiculopathy from confounding neuropathic conditions (eg, ulnar nerve entrapment, carpal tunnel syndrome, peripheral neuropathy, plexopathy).
when are diagnostic injections useful? (neck pain)
If pathology appears to be coming from shoulder, subacromial injections may be helpful
If appears to be coming from cervical spine, selective nerve root injection
who needs surgery with neck pain? (2 groups)
- Neurologic Compromise: Symptomatic nerve root compression refractory to medical management
(Cord compression with myelopathy) - Mechanical Instability
3 mechanical lumbar syndromes (with examples)
- aggravated by static loading of the spine: ie, prolonged sitting or standing
- long lever activities: ie, vacuuming or working with the arms elevated and away from the body
- levered postures: ie, bending forward
mechanical make up about how much of LBP cases?
98%
Others due to systemic, visceral, or inflammatory disorders
nonmechanical back pain types
neurological syndromes, systemic disorders, referred pain
**>50 yo with spine pain, what three things must be in your differential
AAA
Fx (fracture)
malignancy
**<18yo with spine pain, what must be in your differential (5)
Spondylolysis Spondylolisthesis Infection Tumor Developmental disorders
what is most telling for ROM with spine pain ?
forward flexion
muscle testing 0-5: what are 3 important things to watch for?
- Weakness vs. give-way weakness (i.e. drop arm)
- Ratchety weakness (i.e. parkinson)
- SLR: straight leg raise
Dissociation between SLR sitting or lying
ipsilateral leg pain when supine = +
7 Red Flags in spinal exam
B/B incontinence or retention Saddle anesthesia History of trauma Bilateral neurologic deficits Progressive neurologic impairment fever night pains
Dx of spine pain: when are xrays useful
not routine, only if malignancy, infection, fx, spondylosis or listhesis
Dx of spine pain: when is CT useful?
when bony pathology suspected (fx, spondylosis)
Dx of spine pain: when is MRI useful?
for: soft tissue, nerve, routes, couda equina!!!**
HNP and stenosis
urgent studies when red flags present: Xray (4)
Trauma
Children
Infection
Malignancy
urgent studies when red flags present: MRI
Cauda Equina
Epidural hematoma
+ get pre-op labs if you think theyll need surgery
Cauda Equina Syndrome (CES)
Cauda Equina: L2-S4 nerve root (below conus medullaris)
Compression of the roots distal to conus causes paralysis w/o spasticity
what does CES result from? (pathophysc)
relatively sudden reduction in the volume of the lumbar spinal canal that causes compression of multiple nerve roots
what nerve roots are especially vulnerable in CES?
S2-S4 roots that control bladder and anal function are particularly vulnerable
4 general causes of CES
Central disk herniation
Epidural abscess
Spinal trauma: Burst fx with retropulsion or Epidural hematoma
Tumor
symptoms of cauda equina syndrome
Perineal numbness (saddle) ~75%
Urinary overflow incontinence or retention ~90%
Leg weakness (often presents as stumbling gait) / bilateral numbness in legs
Can be immediate or over a few hours or a few days
CES exam shows what two things
Inability to rise from chair without use of armrests: Quad and/or hip extensor weakness
Inability to walk on heels or toes: DF and PF weakness
Dx of CES
MRI (+maybe AP xray for structural problems)
blood labs for suspected infection ( CBC, Creative protein, ESR)
preop labs
Txt + prognosis of CES
txt: Usually requires emergent decompressive surgery
Stop progression of deficits
prognosis Recovery often incomplete
Bowel and Bladder function remain impaired
4 stages of disc herniation
degeneration, prolapse (bulge) , extrusion (leak out) , sequestration (effect to lower spinal levels)
sciatica: technical and real world definition. what would be a better term?
leg pain: 1+ lumbosacral nerve roots, typically L4-S2, with or without neurological deficit.
common definition: leg pain from any lumbosacral segment as sciatica.
Better term: nonspecific radicular pattern
what causes herniated nucleus pulposus (HNP), degenerative disc disease (DDD)? (pathophys)
Discs lose hydration and elasticity with age
Leads to… fissures, loose ligaments, Traction spurs
+ Disk collapse
DDD/HNP –> spondylosis
Canal and foramen narrows
Facet hypertrophy narrows foramen
Osteophytes develop
radicular pain: are both legs hurting the same or one more than the other?
one more than the other
oral pharm options for spine pain
NSAIDS, muscle spasmolytics, neuro pain analgesics (gabapentin), antidepressants (TCAS, SSRIs)
*opiods-last resort or SEVERE ACUTE
4 types of topical therapy for back pain
NSAIDs
Local anesthetics
TCAs
Compounding (combo of drugs)
spinal interventional procedures (7)
Intra-articular facet blocks
Sacroiliac joint injections
Epidural injections
Intradiskaltherapies
Spinal cord stimulation
Implantable intrathecal drug administration systems
surgery( Diskectomy, foraminotomy, medial facetectomy, and/or hemilaminectomy)
is there a relationship between the extent of disk protrusion and the degree of clinical symptoms?
NO!
Sciatica due to lumbar intervertebral disk herniations usually resolves with _______ treatment!
conservative
Txt for acute compression fracture of the spine (6 steps)
Supine: pt remain on their back Logroll: only way they can be moved Examine for other injuries Completion films: x rays Analgesics Brace vs. surgery
what is kyphoplasty?
filling a vertebral body broken from compression fracture w/ cement
spondylolysis vs spondylolithiesis
bone deficit in pars intra-articularis (between superior + inferior articular facet) with…
no slip = spondylolysis
forward slip of one vertebrae = spondylolithiesis
the slip of the vertebrae in spondylolitheisis can compromise what?
either the central canal space and/or the foramina.
what people get spondylolitheisis
More prominent in groups of people who place a lot of stress on their backs (ie. manual laborers, heavy machine operators, and professional athletes)
what is lumbar spine stenosis?
Usually result of aging and everyday wear and tear on the spine
Narrowing of one or more levels of lumbar spinal canal
Compression of nerve roots or conus
cause of lumbar spine stenosis in elderly vs young
In elderly, typically degenerative in origin
In young, d/o that cause small canal
lumbar stenosis symptoms
Insidious or sudden onset without injury Neurogenic claudication Radicular symptoms w or w/o back pain One or both legs Differs from vascular claudication, but can co-exist
what may cause lumbar stenosis patients some relief? why?
Extension of spine narrows the canal and flexion opens the canal
So pts get brief relief by leaning forward, stooping
Ie. Lean over grocery cart
neurogenic vs vascular claudication: back pain (which is common?)
neurogenic: common
vascular: uncommon
neurogenic vs vascular claudication: pain relief
neurogenic: sitting or flexed posture
standing + resting usually not helpful (often slow > 5 min)
vascular: NOT positional
pain relief while standing, ( immediate)
neurogenic vs vascular claudication: ambulatory tolerance
neurogenic: tolerable
vascular: fixed
neurogenic vs vascular claudication: uphill vs downhill
neurogenic: downhill more painful (extended posture)
vascular: uphill more painful
neurogenic vs vascular claudication: bicycle ride
neurogenic: no pain
vascular: pain
spinal stenosis exam findings (5)
True weakness uncommon or late finding Sensory changes segmental if at all Diminished reflexes Normal pulses Normal sphincter tone, though B/B Sx may be present
Dx of spinal stenosis
CT
MRI more precise- just takes longer + more expensive so not as widely used
leg pain predominates and imaging ambiguous, what three tests should you do for Dx?
EMG (electromyography)
SSEP (somaotsensory evoked potential testing)
SNRB (selective nerve root block)
lumbar spinal stenosis txt (4)
NSAIDs (monitor renal function)
Physical Therapy - Aquatics
Epidural Steroid Injections (ESI)
Surgery for those who are becoming non-ambulatory or decreased quality of life
what txt has great outcomes with lumbar spinal stenosis
Surgical decompression
when is low back pain defined as “chronic”?
after 3 months because most normal connective tissues heal within 6-12 weeks, unless anatomic instability persists
Primary cause of absenteeism from work
AND Most common cause of disability in American males < 45
chronic low back pain
chronic low back pain: Of those individuals who remain disabled for more than ___ months, fewer than _____ return to work.
6 months, fewer than 1/2 return to work.
4 barriers to recovery of chronic low back pain (kinda weeds)
medical/surgical (physical) pyschological (i.e. dementia) nonpyschological (i.e. brain damage) social (i.e. compensated unemployment) traumatic factors (i.e. fear) post-traumatic factors (i.e. anxiety/depression)
prognostic red flags for chronic low back pain
- Nonorganic signs and symptoms
- Dissociation between verbal and nonverbal pain behaviors
- Compensable cause of injury (worker’s comp)
- Out of work, disabled, or seeking disability
- Psychological features, including depression and anxiety
- Narcotic or psychoactive drug requests
- Repeated failed surgical or medical treatment for LBP or other chronic illnesses
