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Diagnosis and Management > Orthopedics Back > Flashcards

Orthopedics Back Flashcards

1
Q

Normal Anatomy

A
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2
Q

Back PE

  • General
    • The patient is in no acute _____, m____ and a_____ are appropriate, a____ and o_____ times three.
    • The patient is ambulating with a sm____ and s______ gait putting full weight on both lower extremities with good co_____ and b______.
  • Inspection
    • Gait is with normal coordination and balance and is not br____-based.
    • No visible deformity is noted on inspection. (sc______?)
    • Skin is intact about the lower th_____ and l____/s_____spine.
  • Also:
    • Check ____ ROM and for any tenderness to palpation over greater trochanters
A
  • General
    • The patient is in no acute distress, mood and affect are appropriate, alert and oriented times three.
    • The patient is ambulating with a smooth and symmetric gait putting full weight on both lower extremities with good coordination and balance.
  • Inspection
    • Gait is with normal coordination and balance and is not broad-based.
    • No visible deformity is noted on inspection. (scoliosis?)
    • Skin is intact about the lower thoracic and lumbar/sacral spine.
  • Also:
    • Check hip ROM and for any tenderness to palpation over greater trochanters
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3
Q

Tenderness to Palpation

  • ​Where?
  • Midline / _____spinal?
  • Palpable step-____?
  • _______ (link pelvis to lower spine) joints?
A
  • Where?
  • Midline / Paraspinal?
  • Palpable step-off?
  • SacroIliac joints?
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4
Q

ROM, Sensation, Reflexes

  • Range of motion
    • Flexion (“touch _____”) / Extension
    • L______ Bending / Rotation
  • Sensation
    • D______ map
  • Reflexes
    • P______ (L2,3,4); A______ (S1,2)
A
  • Range of motion
    • Flexion (“touch toes”) / Extension
    • Lateral Bending / Rotation
  • Sensation
    • Dermatome map
  • Reflexes
    • Patellar (L2,3,4); Achilles (S1,2)
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5
Q

Strength

  • Strength (keep in mind that there is overlap…)
    • Hip flexion (L1/L2 → f_____ n.)
    • Hip adduction (L2/L3 → femoral/ob_____ n.)
    • Knee extension (L3/L4 → f_____ n.)
    • Ankle Dorsiflexion (L4 → deep per_____ n.)
    • Great Toe Dorsiflexion (L5 → deep per______ n.)
    • Plantar flexion (S1 → t_____ n.)
    • Knee flexion (L3 - S4 → tibial and co______ peroneal n.)
A
  • Strength (keep in mind that there is overlap…)
    • Hip flexion (L1/L2 → femoral n.)
    • Hip adduction (L2/L3 → femoral/obturator n.)
    • Knee extension (L3/L4 → femoral n.)
    • Ankle Dorsiflexion (L4 → deep peroneal n.)
    • Great Toe Dorsiflexion (L5 → deep peroneal n.)
    • Plantar flexion (S1 → tibial n.)
    • Knee flexion (L3 - S4 → tibial and common peroneal n.)
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6
Q

Common Conditions

  • “________”
    • Lumbar st_____ → Most common cause of low back pain
    • Useful to discuss, since back pain is so common and there often is not a “str_______” cause
  • “_____”
    • Inst_____/ Spondylo______/ Spondylo______
    • Disc h______
    • Spinal st_______
    • Disc______ back pain
    • Spine Ar_____ / Spondylosis
A
  • “Muscular”
    • Lumbar strain → Most common cause of low back pain
    • Useful to discuss, since back pain is so common and there often is not a “structural” cause
  • “Spinal”
    • Instability / Spondylolisthesis / Spondylolysis
    • Disc herniation
    • Spinal stenosis
    • Discogenic back pain
    • Spine Arthritis / Spondylosis
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7
Q

Lumbar Strain → LBP

  • Low back pain affects 50-80% of population in lifetime
    • $100 billion in annual cost
    • Second only to respiratory infection as cause to visit doctors office
  • Muscle strain (“_______ muscle”) is the most common cause of LBP
  • Risk factors → ob______, sm_____, prolonged s_____, heavy l_____, job dis_________
  • Can be from an injury or be spontaneous
  • 90% resolves within ___-year
A
  • Low back pain affects 50-80% of population in lifetime
    • $100 billion in annual cost
    • Second only to respiratory infection as cause to visit doctors office
  • Muscle strain (“pulled muscle”) is the most common cause of LBP
  • Risk factors → obesity, smoking, prolonged sitting, heavy lifting, job dissatisfaction
  • Can be from an injury or be spontaneous
  • 90% resolves within 1-year
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8
Q

Lumbar Strain

  • History
    • Ax____
    • Associated with a_______
    • Characterized by s_____ness and difficulty b_______
  • Symptoms
    • Usually back only (although sometimes “_______ components”)
    • _______ as opposed to directly over spinous process
  • Physical Exam
    • Neurologically “_______”
A
  • History
    • Axial
    • Associated with activity
    • Characterized by stiffness and difficulty bending
  • Symptoms
    • Usually back only (although sometimes “radicular components”)
    • Paraspinal as opposed to directly over spinous process
  • Physical Exam
    • Neurologically “normal”
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9
Q

Lumbar Strain

  • ______ Signs
    • System to evaluate non-organic back pain symptoms
    • Clinically significant if _____ positive signs are present
      • Superficial and ____anatomic tenderness
      • Pain with axial _______ or ______ rotation of the spine (shoulders and pelvis rotated in same plane)
      • _______ straight-leg raise with patient distraction
      • Regional disturbances which do not follow __________ pattern

______reaction to physical examination

A
  • Waddell Signs:
    • System to evaluate non-organic (nothing on scan)back pain symptoms
    • Clinically significant if three positive signs are present
      • Superficial and nonanatomic tenderness
      • Pain with axial compression or simulated rotation of the spine (shoulders and pelvis rotated in same plane)
      • Negative straight-leg raise with patient distraction
      • Regional disturbances which do not follow dermatomal pattern
      • Overreaction to physical examination
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10
Q

Lumbar Strain Imaging

  • XR:
    • Pain lasting > one ______ and not responding to conservative management
    • Red flags are present
      • In______ (IV drug user, h/o of fever and chills)
      • T_____ (h/o or cancer)
      • T_____ (h/o car accident or fall)
      • (1) syndrome (bowel/bladder changes)
  • MRI:
    • _______ sensitive and specific
    • High rate of abnormal findings on MRI in “______ ” people
A
  • XR:
    • Pain lasting > one month and not responding to conservative management
    • Red flags are present
      • Infection (IV drug user, h/o of fever and chills)
      • Tumor (h/o of cancer)
      • Trauma (h/o car accident or fall)
      • Cauda equina syndrome (bowel/bladder changes)
  • MRI:
    • Highly sensitive and specific
    • High rate of abnormal findings on MRI in “normal” people
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11
Q

Lumbar Strain Treatment

  • GOAL
    • Reduce pain / Restore function
    • Can take several ____ to a ____
  • Always non-surgical
    • Rest
    • Lumbar ______ brace
    • NSAIDs (oral or topical)
    • PT/Chro/M_____
    • Injection (_______ → _____ point)
  • Surgery
    • (1)
  • Refer?
    • Red flags
    • No improvement after full course of conservative options
A
  • GOAL
    • Reduce pain / Restore function
    • Can take several months to a year
  • Always non-surgical
    • Rest
    • Lumbar support brace
    • NSAIDs (oral or topical)
    • PT/Chro/Massage
    • Injection (controversial → trigger point)
  • Surgery
    • No surgery exists to address this type of back pain
  • Refer?
    • Red flags
    • No improvement after full course of conservative options
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12
Q

Back Pain - When its not “just muscular”

A
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13
Q

Axial or Peripheral Pain?

  • Axial
    • Disco_____
    • Spondy_____ (e.g. facet joint arthritis)
    • Ins______ (one vertebrae slipping in front of another)
    • Sacro_____
  • Peripheral
    • Neurogenic
      • ______ disc (can send signals down the leg - dermatomes)
      • St_____
      • Spondylitic (if the spondylosis is causing st_____)
A
  • Axial
    • Discogenic
    • Spondylitic (e.g. facet joint arthritis)
    • Instability (one vertebrae slipping in front of another)
    • Sacroiliac
  • Peripheral
    • Neurogenic
      • Herniated disc (can send signals down the leg - dermatomes)
      • Stenosis
      • Spondylitic (if the spondylosis is causing stenosis)
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14
Q

Axial or Peripheral Pain?

  • Often Lots of Overlap…
    • E.g. spondylosis (facet arthritis) can cause st______; disc collapse can cause st______, etc…
  • Without red flags, conservative treatment is similar for all
    • (in____, tu_____, tr_______, c_____ eq_____)
A
  • Often Lots of Overlap…
    • E.g. spondylosis (facet arthritis) can cause stenosis; disc collapse can cause stenosis, etc…
  • Without red flags, conservative treatment is similar for all
    • (infection, tumor, trauma, cauda equina)

Notes: Stenosis is narrowing or compression of the spinal nerves in the lower back due to spinal degeneration (wear and tear)

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15
Q

Cauda Equina Syndrome

  • Cauda Equina Syndrome is caused by severe c_______ of the (1) in the th_____ sac of the lumbar spine, most commonly due to an acute lumbar disc h_______.
  • _______ anesthesia, (2)
  • Treatment is prompt surgical __________ that should preferably be performed within __ hours, absolutely within __ hours.
  • Very rare, but useful to ask brief screening questions during a spine exam.
A
  • Cauda Equina Syndrome is caused by severe compression of the nerve roots in the thecal sac of the lumbar spine, most commonly due to an acute lumbar disc herniation.
  • Saddle anesthesia, urinary retention and loss of bowel control
  • Treatment is prompt surgical decompression that should preferably be performed within 24 hours, absolutely within 48 hours.
  • Very rare, but useful to ask brief screening questions during a spine exam.
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16
Q

Axial

  • (1)
    • Pain from the discs
    • Controversial
    • “Confirmed” by discogram
  • (1)
    • Usually means pain from the facet joints
    • Worse pain with extension (“facet loading”- lead back, lean side to side)
  • (1)
    • Sometimes motion is felt on flexion/extension
  • (1)
    • Localized to the SIJs
    • Various tests, F _ _ _ _ _ is a good screening tool, but not perfect
A
  • Discogenic
    • Pain from the discs
    • Controversial
    • “Confirmed” by discogram
  • Spondylitic
    • Usually means pain from the facet joints
    • Worse pain with extension (“facet loading”- lead back, lean side to side)
  • Instability
    • Sometimes motion is felt on flexion/extension
  • Sacroiliac
    • Localized to the SIJs
    • Various tests, FABER is a good screening tool, but not perfect
17
Q

Peripheral

  • ______ disc
  • St______
  • Sp________ (if the spondylosis is causing stenosis)
  • Symptoms → _____atomal/myotomal
A
  • Herniated disc
  • Stenosis
  • Spondylosis (if the spondylosis is causing stenosis)
  • Symptoms → dermatomal/myotomal
18
Q

Lumbar Spine Imaging

  • XR:
    • Pain lasting > ___ month and not responding to ______ management
    • Red flags are present
      • In______ (IV drug user, h/o of fever and chills)
      • T_____ (h/o or cancer)
      • Tr_____ (h/o car accident or fall)
      • _____ _____ syndrome (bowel/bladder changes)
  • MRI:
    • ______ sensitive and specific
    • High rate of _______ findings on MRI in normal people
      • Need to correlate images with _______ or else they have no clinical significance (not an easy conversation to have with patients)
A
  • XR:
    • Pain lasting > one month and not responding to conservative management
    • Red flags are present
      • Infection (IV drug user, h/o of fever and chills)
      • Tumor (h/o or cancer)
      • Trauma (h/o car accident or fall)
      • Cauda equina syndrome (bowel/bladder changes)
  • MRI:
    • Highly sensitive and specific
    • High rate of abnormal findings on MRI in normal people
      • Need to correlate images with symptoms or else they have no clinical significance (not an easy conversation to have with patients)
19
Q

Lumbar Spine Treatment

  • GOAL
    • Reduce pain / Restore function
    • Can take several months to a year
  • Should almost always be non-surgical
    • Rest
    • Lumbar support brace
    • NSAIDs (oral or topical)
    • PT/Chro/Massage
    • _________ approach - educational and behavioral support
    • Injections
      • Various types - ______ block for axial pain, ______ for peripheral pain
  • Surgery
    • ______ utilized
  • Refer?
    • Red flags
    • No improvement after full course of conservative options
A
  • GOAL
    • Reduce pain / Restore function
    • Can take several months to a year
  • Should almost always be non-surgical
    • Rest
    • Lumbar support brace
    • NSAIDs (oral or topical)
    • PT/Chro/Massage
    • Biopsychosocial approach - educational and behavioral support
    • Injections
      • Various types - facet block for axial pain, epidural for peripheral pain
  • Surgery
    • Overutilized
  • Refer?
    • Red flags
    • No improvement after full course of conservative options
20
Q

Lumbar Spine Injections

  • (1)
    • Facet
    • Sacroiliac
    • Trigger Point
  • (1)
    • Epidural
  • Diagnostic
    • Facet (more diagnostic than relief)
    • Disc
A
  • Axial
    • Facet
    • Sacroiliac
    • Trigger Point
  • Peripheral
    • Epidural
  • Diagnostic
    • Facet (more diagnostic than relief)
    • Disc
21
Q

What does spine surgery do?

  • Spine surgery demystified → all it does is make (1)? (that’s it, no magic)
  • GOAL → Take ______ off the nerves by opening up the ____ tube and/or removing other things like disc material
  • If the spine is unstable, then a “_____” is done to stabilize the spine.
  • Very _____ evidence that fusion for discogenic pain is beneficial
A
  • Spine surgery demystified → all it does is make more room for the nerves (that’s it, no magic)
  • GOAL → Take pressure off the nerves by opening up the bony tube and/or removing other things like disc material
  • If the spine is unstable, then a “fusion” is done to stabilize the spine.
  • Very poor evidence that fusion for discogenic pain is beneficial

Diagnosis and Management (36 decks)

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