Pathologies related to the Low Back I Flashcards
1
Q
What is the incidence of spinal malignancy?
A
- multiple myeloma
- spinal metastasis (secondary)
2
Q
How can multiple myeloma cause spinal malignancy? In what population primarily?
A
- primary malignant tumor in bone marrow
- typically in older individuals
3
Q
What is the most common tumor of the spine?
A
spinal metastases
4
Q
Spinal metastases is the ___ MOST common serious spinal pathology?
A
2nd
5
Q
What areas is spinal metastases most often from?
A
- breast
- lung
- prostate
- kidney
- GI
- thyroid tumors
in this order
6
Q
What is the 3rd MOST common area of metastasis behind lung and liver?
A
- bone
7
Q
What Is the MOST common structure for spinal metastasis?
A
Vertebral body
- mostly in anterior portion leading to wedging
8
Q
What is the most common region for spinal malignancy?
A
- Thoracic
- more than lumbar, rarely in cervical
9
Q
What percentage of spinal malignancy creates cord compression or myelopathy?
A
20%
10
Q
What is the most useful indicator of spinal malignancy?
A
Past medical history
11
Q
What is the pathogenesis of spinal malignancies?
A
- healthy bone replace by tumor
12
Q
What is the standard for imaging of spinal malignancies?
A
MRI
13
Q
What are cancer S&S?
A
- Hx of cancer
- P!- local and referred
- Worsens as the tumor grows and encroaches on other tissue with more inflammation
- Especially at night, due to tumors metabolic activity, and likely at a similar time after falling asleep
- Often invariable with position or movement
- May become constant
- N&V
- Loss of appetite
- Unexplained weight loss of ≥ 5-10% over a 3-6-month period
- Fever, chills, sweats (night)- even in absence of infection due to increased circulating white blood cells (WBCs) or production of pyrogen agent
- Swollen and NON-tender lymph nodes, possibly hard and immobile due to fibrosis
- Unusual malaise and fatigue
- Secondary infections due to lowered immunity
14
Q
What are PT clinical S&S of spinal malignancy?
A
- Cancer S&S
- Spinal pain that is the MOST common initial symptom
- unfamiliar and severe pain that may become progressive and constant
- possible bony alterations, including fractures and subsequent joint instability
- May be unable to lie flat due to pain
- likely mechanical pain with scan and biomechanics exam component that stress vertebral body and lumbar joints will possibly be positive
15
Q
What kind of referral is spinal malignancy?
A
Urgent referral to MD unless cord S&S you would want to immobilize for emergency referral
16
Q
What is the pathogenesis of lumbar myelopathy?
A
- slow, gradual and often progressive compression of cord
17
Q
What level is the end of the spinal cord?
A
L1/2
18
Q
What is the second most common area of spine for compression?
A
Lumbar
19
Q
What is the MOST common etiology of lumbar myelopathy?
A
NOT due to trauma
MOST commonly due to degenerative spinal changes
20
Q
What degenerative spinal changes can cause lumbar myelopathy?
A
- lax and bucking ligamentum flavum
- age related joint disease with enlarging and encroaching arthritic bone aka stenosis
- age related disc disease with herniations
- vertebral body collapse
- pathological instability
21
Q
What is the only validated red flag for lumbar myelopathy malignancy?
A
- history of cancer
22
Q
What will we find in hx for lumbar myelopathy?
A
Slow, gradual and often progressive onset
23
Q
What we we observe with lumbar myelopathy?
A
not acute - won’t splint
24
Q
What will we find with AROM/PROM with lumbar myelopathy?
A
- extreme spinal pain with mechanical reproduction with scan and biomechanical exam possibly for:
> age-related changes
> vertebral body
> instability
25
What stress tests will be positive with lumbar myelopathy?
- PA stress tests possibly positive for neuro symptoms
26
What are clinical manifestations of lumbar myelopathy?
- Multi-segmental numbness and weakness/paralysis of LE and trunk below level of injury likely leading to impaired balance
- DTRs = hyperactive
- UMN tests positive
- Spastic or retentive bowel and bladder
- dural mobility most often negative due to gradual onset
- superficial reflexes = hypoactive
- Less often cancer S&S
27
What kind of referral is lumbar myelopathy?
IMMOBILIZE with emergency referral
28
What is caudal equina syndrome?
compression on some degree of the 20 spinal nerves that originate from the end of the spinal cord or conus medullar is in the vertebral canal
29
Is cauda equina syndrome acute or chronic?
Can be either
30
What segment does the spinal cord end?
L1/2 segment
31
What is the prevalence of cauda equina syndrome?
Rare with 2% of lumbar age-related disc changes
32
What is the etiology of cauda equina syndrome?
- primarily due to mid to lower lumbar age-related disc changes
- secondarily due to other degenerative spinal changes and malignancy
33
What are risk factors for cauda equina syndrome?
- mid to lower lumbar: persistent IDD (central > postlat IDD), central stenosis, surgery
- < 50 years
- Obesity
34
What are the differences between myelopathy and cauda equina syndrome?
- myelopathy = UMN S&S
- Cauda equina syndrome = LMN S&S
35
What are clinical manifestations of cauda equina syndrome?
- hx
- respective S&S of contributing degenerative condition
- likely limited and worse with ext, better with flx
- progressive or altering LE/patchy findings due to movement of spinal nerves
36
What will we find in hx indicating cauda equina syndrome?
- LBP
- Bowel and bladder incontinence
- sexual dysfunction
- possible cancer S&S if malignancy contributing
37
What are the progressive or alternating LE findings due to movement of spinal nerves?
- paresthesias and decreased sensation in multiple dermatomes - saddle/groin area
- Multiple myotomal weakness and gait abnormality
- hypoactive DTRs
- possible positive dural mobility tests
38
What is the gold standard for imaging for cauda equina syndrome?
MRI
39
What kind of referral is cauda equina syndrome?
Emergency referral due to multiple spinal nerves involved
40
What is a spinal infection?
infectious disease of spinal structures
41
What is osteomyelitis?
Bone infection
42
What is discitis?
Disc infection
43
What is the incidence of spinal infections?
- uncommon in weather countries but resurgence with longevity and iV drug use
44
Where is discitis more common?
Lumbar spine
45
What is the etiology of spinal infections?
- primarily from airborne bacteria
- secondarily from staph bacteria that may also be involved
46
What are risk factors for spinal infection?
- Immunosuppression
- surgery, particularly of spine and repeated procedures
- IV drug use
- Social depravation
- Hx of TB or another recent infection
** all low evidence
47
What is the pathogenesis of spinal infections?
- days, months, or years to spread to spine
- infection spreads to disc more commonly in lumbar spine
48
What is not common but may occur as the abscess grows with spinal infections?
- nerve root irritation
- vertebral body collapse/fx
- and cord compression may develop
49
What are clinical manifestations of spinal infections?
- age-related changes with back pain/stiffness is MOST common presenting symptom
- constitutional and infection symptoms NOT common initially
50
What are infection S&S?
- malaise
- fever, chills, sweats
- N&V
- enlarged and likely tender lymph nodes
- redness (maybe lymphangitis or streaks towards lymph nodes), abscess, heat, and/or swelling
- Specific infected system S&S as well
51
What are PT implications of spinal infection?
- localized and PROGRESSIVE spinal pain that limits motion
- likely mechanical pain for disc > vertebral body involvement with scan and biomechanics exam
- Infection S&S particularly fatigue and fever since onset of back p!
52
What can happen if the spinal infection goes untreated?
- unexplained weight loss of ≥ 5-10% over a 3-6 month period with a loss of appetite
- Neuro S&S influence the LEs and coordination as well as bowel and bladder dysfunction
- loss of lumbar lordosis
53
What kind of referral is a spinal infection?
Urgent referral unless cord or cauda equina s&s then emergency referral to MD
54
What kind of imaging should we have done if we are suspicious of TB with a spinal infection?
x-ray
55
What is an MRI showing with a spinal infection?
- can observe infection 3-5 days after onset
56
What are blood tests useful for with spinal infections?
- not diagnostic
- inflammatory markers such as RBC and C-reactive proteins are better indicators of infection than WBC
- presence of normal WBC does not exclude spinal infection
