quiz - spine Flashcards
where is the problem
-Use a pain diagram
-Does it follow a radicular pattern? -> nerve root vs not
-Does it follow a pattern of referred pain?
-Mechanical symptoms?
Red flags
-Is the pain primarily in the back of the leg? -> sciatica
-Bowel or bladder incontinence? -> cauda equina
-Sexual dysfunction? -> cauda equina
Non-dermal or non-anatomic patterns? (e.g..M.S., Lyme, Fibromyalgia)
-DM -> peripheral neuropathy
muscle strength grading
(didnt go over it)- told us to look on our own
grading reflex
-0= absent
-1+ = hyporeflexic
-2+ = normal
-3+ = hyperreflexia
-4+ = clonus
C5, C6, C7, C8, KNOW THIS
-5,6,7- MC pathology here
-motor, reflex, sensation
-C5- deltoid raise, bicep curl, bicep tendon reflex, bicep sensation
-C6- bicep curl, wrist extension, brachioradialis reflex, sensation of first and second fingers
-C7- triceps, middle finger sensation
-C8- no reflex, sensation ulnar aspect of hand
T1, L4, L5, S1 -> KNOW THIS
- T1: interosseous fingers, no reflex, lower elbow sensation
-L4- tibialis anterior (supinate foot), patellar reflex, inside of foot sensation
-L5- lift big toe, no reflex, sensation is the top of the foot
-S1- Achilles reflex, lateral aspect of the foot sensation
spurling test
-Ask the patient to extend the neck while tilting the head to the side
- This narrows the neural foramen and will reproduce radicular arm pain with cervical disk herniations or cervical spondylolysis
axial loading
-with pt standing -> push down on their head
-may provoke neck pain in pts with disk pathology
hoffman reflex
-pts hand relaxed -> flick the long finger nail and look for index and thumb flexion -> sign of upper motor neuron interruption (e.g. cervical herniated disk or stenotic lesion)
superficial abdominal reflex
-pt supine
-Stroke lightly toward the umbilicus.
-Normal = movement of the umbilicus is toward the stimulated side
-Absence of this may suggest spinal cord pathology in the cervical or thoracic region.
-Perform in uppear & lower quadrants on both sides
ankle clonus
-with pt seated, dorsiflex the ankle suddenly and observe for rhythmic beating (clonus)
-Sign of long-tract spinal cord involvement (descending/motor)
straight leg raising
-Places the L5, S1, & sciatic nerves under tension.
-Patient supine
-Elevate the leg approximately 80 deg
-Positive if pt has pain radiating down leg
-pain PAST THE KNEE
cross leg straight leg raise test
-Supine and raise uninvolved leg
-A greater degree of elevation is usually required
-Pain will radiate on leg not being raised
reverse straight leg raise
-Places L1-4 nerve roots under tension
-Pt is prone and the hip is lifted into extension while keeping the knee straight
-Increased pain suggests compression of upper lumbar nerve roots
common spinal conditions <10yo
-Congenital Kyphosis
Scoliosis
Intervertebral diskitis
Myelomeningocele- backbone and spinal canal do not close before birth -> type of spina bifida
Osteoblastoma- tumor that replaces bones with osteoid -> benign
Leukemia
spinal cord
-ascending fibers- deliver deep touch and vibration, proprioception
-lateral spinothalamic tract- pain and temp (ascending)
-lateral corticospinal tract- voluntary muscle contraction (descending)
common spinal conditions: 11-19yo
-spondylolisthesis
-kyphosis (scheuermanns disease)
common spinal conditions: 20-29yo
-disk injuries (central disk protrusion, disk sprain)
-spondylolisthesis
-spinal fracture
common spinal conditions: 30-39yo
-cervical and lumbar disk herniation or degeneration
common spinal conditions: 40-49yo
-cervical and lumbar disk herniation or degeneration
-spondylolisthesis with radicular pain
common spinal conditions: 50-59 yo
-disk degeneration
-herniated disk
-metastatic tumors- bone pain that keeps the pt up
common spinal conditions: >60yo
-Spinal stenosis
-Disk degeneration
-Herniated disk
-Spinal instability
-Metastatic tumors
common terms: Radiculopathy, Myelopathy, Mechanical Pain, Neurogenic Claudication
Radiculopathy
-Dysfunction of a nerve root
-Signs & Symptoms: Pain in the distribution of that nerve root
-Dermatomal sensory disturbances.
-Weakness of muscle innervated by that nerve root.
Myelopathy
-Abnormal condition of spinal cord through ds or compression
-Usual consequences are spasticity, impairment of sensation, & impairment of bowel or bladder function
Mechanical Pain
-AKA musculoskeletal back pain
-MC form of back pain
-May result from strain of paraspinal muscles, ligamentous injury, irritation of facet joints (excludes anatomic causes, e.g. herniated disk, tumor)
Neurogenic Claudication
-“Pseudoclaudication”
-Symptom of Lumbar stenosis causing impingement or inflammation on the nerves
-Symptoms proximal to distal (vascular is distal to proximal)
-Walking & standing causes fatigue & weakness is not relieved with sitting (vascular is relieved with sitting)
-paravertebral discomfort relieved with rest and aggravated by activity = what?
-young pt with abnormal upper extremity neuro exam = what?
-older pt with limited ROM and pain on extension -> ?
-urinary dysfunction with global sensory changes, weakness, and abnormal gait -> ?
-shoulder pain and positive impingement -> ?
-tinel sign and non-dermatomal distribution of sx -> ?
-paravertebral discomfort relieved with rest and aggravated by activity -> acute neck sprain
-young pt with abnormal upper extremity neuro exam -> cervical radiculopathy due to herniated nucleus pulposus
-older pt with limited ROM and pain on extension -> cervical radiculopathy due to cervical spondylosis
-urinary dysfunction with global sensory changes, weakness, and abnormal gait -> cervical myelopathy secondary to cervical spondylosis or trauma
-shoulder pain and positive impingement -> shoulder pathology
-tinel sign and non-dermatomal distribution of sx -> peripheral nerve entrapment
back pain
-90% of people in their life
-2nd MC reason people seek doctor
-initial assessment is geared at detecting red flags
-without red flags -> imaging is low yield in first 4 wks
-Paravertebral discomfort relieved with rest and aggravated with activity -> ?
-Limited motion or stiffness -> ?
-Unrelenting night pain and weight loss -> ?
-Fever chills and sweats -> ?
-A younger patient with an abnormal lower extremity neurologic examination ->?
-An older patient with poor walking tolerance and a stooped gait ->?
-Tenderness over the lateral hip and discomfort at night -> ?
-Paravertebral discomfort relieved with rest and aggravated with activity -> acute low back sprain
-Limited motion or stiffness -> degenerative disk disease, ankylosing spondylitis
-Unrelenting night pain and weight loss -> tumor
-Fever chills and sweats -> infection or intervetebral disk infection
-A younger patient with an abnormal lower extremity neurologic examination -> lumbar radiculopathy due to herniated nucleus pulposus
-An older patient with poor walking tolerance and a stooped gait -> spinal stenosis
-Tenderness over the lateral hip and discomfort at night -> trochanteric bursitis
back pain red flags
-cancer or infection:
->50 or <20 yo
-h/o CA
-wt loss, fever, chills, immunosuppression
-UTI, IVDA, prolonged steroids
-back pain not improved with rest
-spinal fracture:
-h/o trauma, MVA, fall from ht
-osteoporosis
->70yo and minor trauma
-cauda equina syndrome or severe neurologic compromise:
-acute onset urinary retention or overflow incontinence
-fecal incontinence, decrease rectal tone
-saddle anesthesia
-global progressive weakness in LEs
cervical radiculopathy
-Def: Referred neurogenic pain in the distribution or a nerve root, with or without numbness, weakness, or loss of reflexes
MOA:
- herniated nucleus pulposus in young pt (< 40)
-Older pts -> MC foraminal narrowing from degenerative disk & arthritic facet joint
-Sx: neck pain, radicular pain, numbness, muscle spasms, decreased grip strength, loss of coordination
-P/E: Loss of cervical lordosis, decreased ROM, + SPURLING test.
-Look for changes throughout C4-C7 neuro exam (Pain, Sensory change, Motor weakness atrophy, Reflex change)
-Dx tests: X-Ray, MRI or CT confirms dx (not necessary routinely), Electromyography (EMG) - reserved for preop planning
Tx:
- Resolution of sx usually within 6-12 wks
-NSAID’s, oral steroids, phys therapy
-Referrals/Red Flags: Failure of conservative tx, atrophy, motor weakness, signs of myelopathy, infection, tumor
cervical spondylosis
Def: Degenerative disk ds or cervical ARTHRITIS
-MOA: Bone spurs, buckling of the ligamentum flavum, herniated disk -> All result in narrowing of neural foramen and possible stenosis of canal
Sx:
- Stiffness & neck pain worse UPRIGHT
- Muscle spasm, pain with ROM
P/E:
- Lateral tenderness, spinous process tenderness, Decreased ROM,
-Look for changes throughout C4-C7 neuro exam (Pain, Sensory change, Motor weakness atrophy, Reflex change)
Dx Tests: X-rays (degenerative changes MC @ C5-6 & C6-7)
Tx:
- NSAID’s, Supportive (cervical pillow, sleep on side) P.T.
-Surgical decompression (laminectomy) - indicated with intractable pain, progressive neurologic findings, cervical myelopathy, spinal cord compression
-Referrals/Red Flags: Same as reasons for surgery
cervical sprain
-Neck Strain
-“muscle” injury in the neck
-R/o unstable injuries & neuro dysfunction -> then provide symptomatic tx
-Whiplash in MVA is very common
-Sx: Nonradicular, nonfocal neck pain anywhere from the base of the skull to the cervicothoracic junction.
-Pain with motion, spasm, h/a
-P/E: Paraspinous tenderness, decreased ROM, normal neuro exam
-Dx Tests: X-rays (AP,Lateral & odontoid views if trauma or neurologic deficit
-Tx: Reassurance, Soft collar, NSAID’s, muscle relaxers, cervical pillows, physical therapy
-Encourage a return to normal activities!
-Referral/Red Flags: Pain refractory to tx, nerve root deficit, myelopathy
cervical fracture
-result of high energy trauma
-Sx: Severe pain, spasm, POINT TENDERNESS
-Global sensory or motor deficits suggest spinal cord injury
-P/E: Palpate for tenderness and spasm.
-Feel for any gaps or step-off
-Check sensory of dermatomes and motor function -> Perianal sensation, sphincter tone & bulbocavernosus reflex should be assessed
-Bulbocavernosus reflex = stimulate glans penis or clitoris and monitor anal tone -> Often monitored via emg.
-Dx Tests: AP, Lateral, Odontoid
-Injuries @ upper & lower portions of C-Spine most often missed.
- -!! acute situation CT scan is obtained**
-AP- malalignment of spinous processes
-Lateral- anterior soft-tissue swelling, vertebral height, alignment of vertebral bodies, facet joints, & spinous processes
Odontoid- subtle fracture, C1 lateral mass widening, occipital condyle position
-Swimmers View - visualizes cervicothoracic junction
-Carefully evaluate radiographs
-Signs of instability (dont memorize #s)
->3.5 mm translation of a vertebral body
->11 degrees of angulation of adjacent vertebral bodies
-Tx: Immobilization and/or surgical management if indicated
-high suspicion for injury in pts intoxicated, uncooperative, or unconscious
fracture of thoracic and lumbar spine types and PE, sx
-high-energy trauma
-Can occur with minimal trauma in those with osteoporosis, tumors, infection, chronic steroid use
-Sx: Moderate to severe back pain. Worse with motion.
-P/E: Step-off or gap between spinous processes with swelling & hematoma are classic in an unstable flexion-distraction or burst fracture
-Neuro exam, Perianal sensation, sphincter tone & bulbocavernosus reflex should be assessed
Types:
-Simple Compression Fracture - involve only the anterior half of the vertebral body are stable
-Burst Fracture - compression fracture that extends to the posterior third of vertebral body
-Flexion-distraction - disrupts anterior & posterior bone & ligamentous structures. Highly Unstable!
fracture of thoracic and lumbar spine dx and tx
-Dx. Tests: AP & Lateral X-rays
-!!In acute situation CT scan is obtained**
-AP: Look for transverse fractures or widening of the interpedicular distance (unstable burst)
-Lateral: Loss of height of the anterior wall and resultant kyphotic deformity. Widening of the space between adjacent spinous processes
Tx: Goals
-1) Prevent neurologic damage
-2) Restore stability
-3) Restore Normal function
-Hyperextension bracing, Pain management, phys. Therapy, encouragement,
-Surgical intervention
kyphoplasty/vertebroplasty
Kyphoplasty = cement is injected into a balloon
Vertebroplasty = cement injected into vertebra
low back sprain
-Muscular low back pain / Lumbar pain
-< 45 y.o. = MCC of loss of work & disability
-4% of pts have sx that last >6 months & generate 85-90% of costs to society for treating LBP
-RF: repeated lifting/twisting, vibrating equipment, poor fitness, poor work satisfaction, smoking, illness anxiety disorder (hypochondriasis)
-Sx: radiates into buttocks and posterior thighs, Pain with lifting and rotation.
-P/E: Diffuse paraspinal tenderness, Decrease ROM, Motor, Sensory and reflexes are normal
-Dx. Tests: X-rays show degenerative signs and are often not useful -> BUT are necessary to r/o other causes.
-Tx: - Bed rest? (1-2 days only) -> avoid it -> keep moving!
-NSAID’s, muscle relaxers, APAP, Physical therapy
-Referral/Red Flags: Neurologic abnormalities, unresponsive pain
degenerative disk ds
-Degeneration of intervertebral disk - physiologic event of aging
-Sx: - Usually between 3rd & 6th decade
-Recurrent & episodic
-LBP that radiates to buttocks
-“Mechanical” pain
-Relieved with lying down
-Depression complicates chronic LBP
-P/E: - Lumbar & Sacroiliac tenderness.
-Muscle spasm
-Motor, Sensory, Reflexes are normal
Dx.
- X-Rays: AP & Lateral: osteophytes, reduced height of intervertebral disks
tx:- chronic pain management problem
-NSAID’s, APAP, Lifestyle changes (wt loss, smoking cessation, increased physical activity)
-Physical therapy
-Referral/Red Flags: Fever, chills, unexplained wt loss, Ca, significant night pain, pathologic fracture, loss of bowel or bladder function, abdominal pain, saddle anesthesia
lumbar herniated disk
-Sciatica / Lumbar radiculopathy
-Pain from direct compression of the nerve root & in part from chemical irritation of the nerve root by substances in the nucleus pulposus
-Affects 2% of the population
-10- 20% of those pts have sx lasting longer than 6 wks
-Sx: Unilateral radicular leg pain with LBP
-Pain worse with sitting
-Lying relieves pain
-P/E: Inspect for list to one side
+ SLR test or contralateral SLR test
-Dx. Tests: -X-rays: show degenerative changes
-MRI for dx or pre-op planning
Tx:
-1-2 days bed rest for acute episode
-NSAID’s, APAP, Muscle relaxers, Oral steroids, epidural injections, Phys. therapy
-Referral/Red flags: Cauda equina syndrome, urinary retention, perianal numbness, motor loss, severe single nerve root paralysis, progressive neurologic deficit, radicular symptoms >6wks
lumbar herniated disk classic findings:
- L3-4
- l4-5
- l5-s1
-L3-4 disk (5%): Ant tib weakness, numbness in shin, asymmetric knee reflex
-L4-5 disk (67%): EHL weakness, numbness top of foot & 1st webspace
-L5-S1 disk (28%): Weakness with plantar flexion (gastrocsoleus, numbness lateral foot, asymmetric ankle reflex
lumbar spinal stenosis
-Neurogenic claudication
-Narrowing of the lumbar spinal canal & subsequent compression of the nerve roots
-30% of the population >60 y.o.
-L4-5, L3-4, L1-2 MC
-must have Severe stenosis before symptoms occur
-Sx: Neurogenic claudication with radicular complaints
-Proximal → Distal
-Pain with walking that does not subside when walking stops
-Pain with extension (narrows the canal)
-P/E: - Muscle weakness in legs
-Can have sensory changes
-Can have diminished reflexes
-Dx. Tests: X-rays: AP & Lateral
-May show intervertebral disk narrowing, spondylolisthesis, osteopenia
-MRI to confirm
-Tx:
- * Prevent progression*
-Physical therapy, Abdominal muscle strength, weight loss, lumbar flexion exercises, NSAID’s
-50% relief with injections
spondylolisthesis: degenerative
-Forward slippage of a lumbar vertebral body
-Caused by degeneration & alterations in facet joints along with degeneration of intervertebral disk
-The lamina and pars interarticularis are intact
-M.C. 4th & 5th vertebral bodies
-Woman >40 y.o.
-Sx: Back pain aggravated with activities
-P/E:
-Note gaps or step-off
-Evaluate motor, sensory function & reflexes (diminished knee & ankle reflexes)
-Dx. Tests: X-rays: AP & Lateral
-Lateral shows slippage of one vertebra onto another
-Degenerative changes and vertebral space narrowing
Tx:
- Flexion exercises, stretching, corset, NSAID’s.
-Lifestyle changes
-MRI & consideration of surgical stabilization
spondylolisthesis: isthmic
-Forward slippage of a lumbar vertebral body
-In children between L5 & S1
-!Defect! at junction of lamina with the pedicle (pars interarticularis), leaving the posterior element without a bony connection
-“Fatigue Fracture”
-Defect only = Spondyloysis
-Gymnasts/Football players
-Sx: - Asymptomatic/minimal sx/back pain with posterior radiation
-Hamstring spasms & limited hamstring flexibility
-P/E: - Palpate for step-off
-Diminished lordosis
-Neurologic deficits are rare
-Dx.Tests: - X-Rays- AP/lateral/oblique. Absent neck in the “Scotty Dog”(pars interarticularis defect)
-Differential: Intervertebral disk injury
-Tx: Strengthening with P.T.
-Periodic (6mo) radiographs until growth is complete
-Modification of activities
-Thoracolumbosacral orthosis for pain relief
-Surgical fusion for progressive slippage
-referral/red flags -> progressive slippage and significant pain
cauda equina syndrome: causes, sx, classic patterns
-conus medullaris (distal spinal cord) terminates at L1-2.
-Spinal canal is filled with L2-S4 nerve roots= Cauda Equina
-sudden reduction in the volume of the lumbar spinal canal causes compression and paralysis of roots distal to the conus
-Prevalence is low: 1-2% of patients who undergo surgery for HD. .0004 in all patients with LBP
-Causes:
-HD
-Epidural abscess
-Epidural hematoma
-Fracture
-Sx: - Radicular pain and numbness in legs
-Pain decreases as paralysis progresses
-Difficulty voiding or loss of urinary and anal sphincter control
-Urinary retention is most consistent feature (90% sensitive)
-Saddle anesthesia
-3 Classic Patterns
-Group 1: Sudden onset with no previous symptoms
-Group 2: Previous low back pain and/or unilateral radicular symptoms that results in cauda equina syndrome
-Group 3: Low back pain and bilateral radicular symptoms that evolve into cauda equina syndrome
cauda equina syndrome dx and tx
-P/E:
-Observe: Inability to rise from seated position or walk on heels and toes (multiple nerve root dysfunction)
-Evaluate motor and sensory function
-Anal sphincter tone and perianal numbness
-Dx Tests:
-X-Rays: evaluate for fracture , spondylolisthesis
-CBC & ESR to r/o infection
-Differential: Guillain-Barre Synd., HD, Mets, MS, Spinal cord tumor
-Tx: Surgical Emergency - Requires immediate decompression
spinal orthotics: soft cervical collar (dont need to know orthotics)
-Short-term use in cervical sprains or intermittent use with cervical spondylolysis
-Position the neck in approx. 10 degrees of flexion
-Maintain isometric exercises with its use
spinal orthotics: philadelphia collar
-Provides better control of rotation
-Used for acute sprains or suspected fractures
spinal orthotics: rigid cervical orthotic
-Miami J orthosis
-Hard cervical collar that limits flexion & extension
-Has a rigid plastic component that extends to chest
spinal orthotics: halo brace
-Provides superior immobilization to the C-spine
-Virtually no cervical spinal motion occurs
spinal orthotics: thoracolumbosacral corset
Provides support for patients with osteoporosis or acute thoracic sprains
spinal orthotics: jewett three point orthosis
-Three-point fixation over sternum and pubis anteriorly and mid-spine posteriorly
-Limit flexion/extension. Allows limited rotation
-Used for thoracic sprains and simple compression fractures
spinal orthotics: total contact thoracolumbar orthosis
-Prefabricated modules or made from a plastic mold based on patient’s measurements
-Used as definitive treatment in patients with stable burst fractures of the thoracolumbar spine or as post-op aid after spinal fusion
spinal orthotics: elastic belts
May provide some lumbar and abdominal support with mild strains
spinal orthotics: lumbosacral corset
-Limit motion and are useful for a lumbar strain or acute HD
-Limit its use and provide back strengthening once its use is completed
cervical facet injection
-Can be used to dx or treat
-Local anesthetic & corticosteroid
-Done under fluoroscopy
interlaminar epidural injection
-Into the epidural space (surrounding the dura)
-Herniated Disk / Degenerative changes
-Local anesthetic & corticosteroid
-Done under fluoroscopy
lumbar caudal epidural injection
-Into the epidural space (surrounding the dura)
-Herniated Disk / Degenerative changes
-Often used when patient has hardware in place
-Local anesthetic & corticosteroid
-Done under fluoroscopy
surgical tx for back pain: when is it indicated
-In general surgical intervention is not recommended for primary back pain
-There is not positive outcomes in terms of pain relief, return to work or improved functional ability
-Surgical indications include pain not responsive to conservative care
-Urgent Surgery;
-Cauda equina syndrome
-Progressive motor deficit (e.g. foot drop)
-Pain (relative indication)
surgical tx: cervical herniated disk
- anterior cervical disketomy and fusion (ACDF)
- needs 1-2 days in hospital
surgical tx: lumbar herniated disk
-Usually Microdiscectomy - Can be outpatient
-Chances of recurrent HD are 4-10% and greatest in the first year
surgical tx: spinal stenosis
Lamincectomy - Removes the lamina to relieve pressure on the nerve roots. Also allows access to the disk
surgical tx: disk replacement
-Preserve motion thus preventing adjacent level breakdown and allowing for more normal biomechanics
-Long-term data not available
-Technically difficult operation
A 48 y.o. Female presents to the urgent care clinic complaining of severe low back pain for the past 3 days. It first began while she was stretching her back before exercising. The pain is constant, 8 out of 10 in severity, and shoots down her right leg from her buttocks to her feet like a “lightening bolt”. She denies fevers, chills, nausea, vomiting, weight loss, or recent trauma. On exam she has a positive straight leg raise and crossed straight leg left test, and her patella reflexes are 2+ on the left and 0 on the right. The achilles reflexes are 2+ bilaterally. Her right quadriceps is weaker than her left, and she is unable to dorsiflex her right foot with any power. Plantar-flexion seems to be spared.
The diagnosis and treatment for this patient are:
Cauda equina syndrome, immediate surgical consult
Spinal stenosis, corticosteroids
Musculoskeletal strain, acetaminophen and restricted activity
Spinal cord tumor, immediate local irradiation
Radiculopathy, anti-inflammatories
The diagnosis and treatment for this patient are:
Cauda equina syndrome, immediate surgical consult
Spinal stenosis, corticosteroids
Musculoskeletal strain, acetaminophen and restricted activity
Spinal cord tumor, immediate local irradiation
Radiculopathy, anti-inflammatories
e)
e) Radiculopathy, anti-inflammatories
“Classic”- pain shooting from back down leg = radiculopathy
Loss of patella reflex and normal achilles= radiculopathy to L4
Weakness of dorsiflexion= L5 is involved
Normal achilles reflex & normal plantar flexion = S1 is spared
