Orthopedic Approach to Back Pain Lecture Powerpoint Flashcards
There are __ cervical vertebrae and ___ cervical nerve roots
7, 8 (remember they exit above except for C8 nerve root which exits below C7 and then T1 onward they exit below as well)
Spondylosis
2ndary degenerative changes including disc degeneration, dessication, height loss, herniation, joint degredation, ligamentous thickening and infolding, as well as deformity such as kyphosis, common finding in many by age of 40-60, typically episodic, exacerbated with extension, sees occipital headaches (cervicogenic pattern)
Most common level for spondylosis to occur? How can spondylosis be diagnosed? (2)
C5-6 most often
- MRI
- CT myelography
Recall the annulus fibrosis and nucleus pulposis
Annulus fibrosis is the outer portion of the intervertebral disk (type 1 collagen) and the nucleus pulposis (type 2 collagen) is the shock absorbing gel that is inside
What is normal space available for the spinal cord in an adult? What is considered true nerve compression?
> 17mm. <14mm
Spondylosis treatment options (6)
- NONSURGICAL first line**
- NSAIDS
- short term narcotics for acute flare such as tramadol
- facet injections
- PT/OT
- surgical treatment for instability (not for isolated neck pain, that won’t help)
Cervical radiculopathy definition
Clinical symptom of nerve root compression resulting in sensory/motor symptoms of the upper extremity caused by things such as cervical spondylosis, disc herniation, etc, typically will complain of dermatomal unilateral upper extremity pain
How would you test for C5 radiculopathy? (sensory and motor and reflex)
- The upper anterior shoulder
- Deltoid/biceps
- biceps reflex
What root is affected by posterolateral C5-6 herniation?
C6 nerve
Cervical radiculopathy treatment options (6)
- NON operative 75% of the time***
- NSAIDS
- PT
- Antidepressants or anticonvulsants for chronic neuropathic pain
- oral corticosteroids for acute flares
- gold standard surgical treatment is anterior cervical decompression and fusion (ACDF)
How would you test for C6 radiculopathy? (sensory and motor and reflex)
- the middle shoulder down the arm straight to the thumb
- Biceps/wrist extension
- brachioradialis reflex
How would you test for C7 radiculopathy? (sensory and motor and reflex)
- The posterior shoulder down the arm straight to the 2nd and 3rd digits of the hand
- Triceps/wrist flexion
- triceps reflex
How would you test for C8 radiculopathy? (sensory and motor and reflex)
- The corner of the axilla down the arm straight tot he 4th and 5th digits of the hand
- finger flexion
- no specific reflex
How would you test for T1 radiculopathy? (sensory and motor and reflex)
- The back heading toward the axilla just below the corner from where the arm leaves and the most medial aspect of the arm going down
- finger abduction
- no specific reflex
What root is affected by foraminal stenosis C5-6 hernaition?
C6 nerve
What root is affected by midlateral C5-6 herniation?
C6 or C7 if big enough
What root is affected by posterolateral C7-T1 hernation?
C8
Spurlings maneuver
Provacative test to reproduce cervical radiculopathy radicular pain pattern, maximally extend and rotate at the neck toward the involved side then apply vertical force downward
Shoulder abduction test
Shoulder abduction bringing relief of cervical radiculopathy symptoms
Cervical myelopathy presentation (3)
- subtle clumsiness of hands and gait imbalance in early manifestations
- dropping things, inability to manipulate small objects
- physical weakness upper extremity early and lower extremity late stage (either severe or coexistent lumbar stenosis)
Cervical myelopathy definition
Caused by spinal CORD compression rather than a specific nerve root from wear and tear of aging
Cervical myelopathy causes (5)
- ossification of posterior longitudinal ligament
- congenital stenosis
- tumor/abscess
- spondylosis
- trauma
Lhermitte’s sign
Electric shock like sensations down spine or legs with certain positions of the neck, indicating MS, cervical spondylosis, cervical disk herniation, etc
Finger escape sign
Test for cervical myelopathy where when asked to hold fingers extended and adducted the small finger abducts spontaneously due to weak intrinsics
Grip/release test
Test for cervical myelopathy asking patients to make fist 20 times in 10 seconds, if fail then positive for cervical myelopathy
Babinski reflex
Test used sometimes for cervical myelopathy that should be positive in new borns but negative in those 2 and older where when the sole is stimulated the toes fan out if positive
Hoffmans sign
Test used for cervical myelopathy where involuntary flexion of index and or thumb occurs when snapping the middle finger distal phalanx downward
Cervical myelopathy treatment options (3)
- stop progression, not improve symptoms, damage is often irreversible
- mild dz NSAIDS with frequent follow up needed
- surgery for severe progressive symptoms
Ossification of the posterior longitudinal ligament is most commonly seen in what population?
Asian
Causes of low back pain (5)
90% resolves in __
- muscle/lig strain
- facet joint arhtropathy
- annular tears or discogenic pain
- spinal stenosis
- spondylolithesis
-1 year
Waddell signs
Signs of nonorganic (kinda sorta faking it) back pain, clinically significant if 3 positive signs are present
- superficial and nonanatomic tenderness
- pain with axial compression or simulated rotation
- negative straight leg raise while patient is distracted
- nondermatomal regional pain pattern
- overreaction on physical exam
When is x ray indicated for lower back pain?
->6 weeks or when red flags are present
Low back pain treatment options (3)
- NSAIDS
- PT
- surgical fusion
Lumbar disc herniation is more common in what gender? What is the most common level? What happens over time with most?
Men, L5-S1>L4-5, Macrophages reabsorb and diminish size over time
How would you test for an L1-3 radiculopathy? (sensory and motor and reflex)
- Hip to groin and inner thigh
- Hip flexion
- No reflex
How would you test for L4 radiculopathy? (sensory and motor and reflex)
- anterior thigh going down to front of knee
- Knee extension/foot dorsiflexion
- patellar reflex
How would you test for L5 radiculopathy? (sensory and motor and reflex)
- anterior shin going down to the toes
- Great toe extension
- trendelenberg gait
How would you test for S1 radiculopathy? (sensory and motor and reflex)
- outer shin down to the pinky toe
- Foot planterflexion/eversion
- achilles reflex
Types of lumbar disk herniation
- Protrusion/prolapse (bulging thru intact annulus)
- Extrusion (disk material crosses annulus and is projecting out)
- Sequestered (free fragment of nucleus pulposis)
Posteriolateral L4-5 Disc herniation affects what nerve root?
L5 nerve root
Far lateral L4-5 Disc herniation affects what nerve root?
L4 nerve root
Lumbar disc herniation treatment options (2)
- NSAIDS and PT
- Partial discectomy surgery within 3-4 months if not resolving, absolutely indicated in cauda equina or progressive neurologic deficit
Lumbar spinal stenosis cause
Not understood, congenital, acquired, both
Lumbar spinal stenosis symptoms (3)
- leaning forward alleviates symptoms
- Extension of spine decreases space worsening symptoms
- pain, paresthesias, subjective weakness or heaviness in back, buttock, and lower extremities
Lumbar spinal stenosis treatment options (3)
- NSAIDS and PT
- Gabapentin for nerve pain
- Surgery such as laminectomy
Degenerative disk disease most common affects what disks first?
L4-5>L5S1
Spondylosis vs spondylitis vs spondylolysis vs spondylolithesis
- Degeneration of intervertebral disks
- Inflammation of the vertebrae
- fracture of pars interarticularis without vertebral transfer
- fracture of pars interarticularis with vertebral transfer
