Review of functional anatomy of the spine and clinical correlations Flashcards
What are the most often identified causes for low back pain?
- Intervertebral disc rupture and herniation
- Nerve inflammation or compression
- Degenerative changes in vertebral facet joints
- Sacroiliac joint and ligament involvement
- Metabolic bone disease
- Psychosocial factors
- Abdominal aneurysm
- Metastatic cancer
- Myofascial disorders
Symptoms of back pain?
and
Neurologic symptoms related to spinal nerve roots or cord compression?
* Neck, mid-back, low back pain, stiffness and loss of function
* Neurologic symptoms related to spinal nerve root(s) or cord compression:
- Extremity pain
- Numbness
- Tingling
- Weakness
- Bowel/bladder urgency/incontinence
Components of musculoskeletal spine examination?
- Inspection/observation
- Palpation
- Range of motion
- Neuromuscular examination
- Special tests
- Examination of related areas
14 yo girl with flaccid paralysis limited to right arm. No pain, paresthesias, sensory loss noted. Laboratory results reveal polio virus infection. Identify the target.
and WHY
Ventral horn of the spinal cord gray matter
NOT
Dorsal rami of spinal nerves
Dorsal rami of spinal nerves
Ventral rami of spinal nerves
Only the ventral horn (and also ventral root) are motor. Dorsal root is sensory. All rami are mixed.
What is a myotome?
What is a dermatome?
A myotome: is a collection of muscle fibers innervated by the motor axons within each segmental nerve (root)
A dermatome: is an area of skin innervated by the sensory axons within each segmental nerve (root)
For dermatomes…
What types of cells?
Where do they reside?
How many pairs?
What is the top of the head dermatome?
What about the face?
Pseudounipolar cells
With their cell bodies residing in Dorsal Root Ganglions
31 pairs of spinal nerves
C2 innervates the top of the head because C1 contributes little to skin
Over the anterolateral head the skin is innervated by one of the three divisions of the trigeminal cranial nerve.
What is shingles/herpes zoster?
Shingles or Herpes Zoster
Is the most common infection of the peripheral nervous system.
Is an acute neuralgia confined to teh dermatome distribution of a specific spinal or cranial sensory nerve root.
What is the manual muscle testing scale?
5-Examiner cannot overcome
4-Examiner can overcome
3-No resistance
2-No gravity
1- Flicker or trace of contraction but no joint motion
0-No contraction palpated
Thoracic spine manual muscle testing.
C5- Biceps-Elbow flexor
C6-Extensor carpi radialis-Wrist extensor
C7-Triceps-Elbow extensor
C8-Flexor digitorum profundus (3rd)-Distal finger flexor
T1-Abductor digiti minimi-little finger abduction
Causes of muscle weakness?
Muscle strain
Pain/reflex inhibition
Peripheral nerve injury
Nerve root lesion (myotome)
Upper motor neuron lesion
Tendon Pathology
Avulsion
Psychologic overlay
Lumbar spine exam manual muscle testing
L2-Iliopsoas-Hip flexor
L3-Quadriceps-Knee extensor
L4-Tibialis anterior-Ankle dorsiflexor
L5-Extensor hallicus longus-Big toe extensor
S1-Gastrocnemius-Ankle plantarflexor
Reflex testing scale
Grading MSR: NINDS scale
0-absent
1-slight or less than normal (trace response or response only broughtout with reinforcement)
2-Lower half of normal (low-normal)
3-Upper half of normal (high-normal)
4- Enhanced and more than normal (inclu. clonus)
Cervical spine reflex testing
C5-Biceps
C6-Brachioradialis
C7-Triceps
Lumbar spine reflex testing
L4-Quadriceps (patellar)
L5-Medial hamstring
S1-Gastrocnemius (Achilles)
What are the special tests of the cervical and lumbar spine?
Cervical
Lhermitte’s sign
Spurling’s Neck Compression test
Hoffmann’s sign
Lumbar
Straight-leg raising test (SLR or Lasegue sign)
Femoral nerve stretch test (upper lumbar disc)
What is Lhermitte’s sign?
Passive anterior cervical flexion elicits electric-like sensation down spine or extremities, implying CERVICAL SPINAL CORD PATHOLOGY
What is Spurling’s Neck Compression test?
Reproduction of radicular symptoms with cervical spine extension, rotation, and lateral flexion.
Implies CERVICAL NERVE ROOT PATHOLOGY
What is Hoffmann’s sign?
Flick the patient’s middle finger (passive snapping flexion of middle finger distal phalanx)
Positive test is flexion-adduction of ipsilateral thumb and index finger.
Implies UPPER MOTOR NEURON PROCESS AFFECTING CERVICAL SPINE OR BRAIN
What is the Straight-leg raising test (SLR or Lasegue sign)?
Patient lies supine while leg raised with knee extended. Examiner stops raising leg when patient reports pain.
Positive test is leg pain reproduced at 30-70 degrees angle.
Implies LUMBAR NERVE ROOT PATHOLOGY (L5 or S1)
What is the Femoral nerve stretch test (upper lumbar disc)?
Patient placed in prone position while knee is flexed.
Positive test is reproduction of patient’s pain in anterior thigh
Implies UPPER LUMBAR NERVE ROOT PATHOLOGY (L2-L4)
What would make you think of an UMN injury?
(Spinal cord injury, Brain injury/stroke, Myelopathy, CNS lesion)
Spasticity/hypertonicity
Increased reflexes (hyperreflexia)
Positive pathological reflexes
Extensor plantar response
What should make you think of a lower motor neuron injury? Begins with the anterior horn cells of the spinal cord and includes the peripheral nerves
(Peripheral nerve entrapment, radiculopathy)
- Flaccid weakness
- Loss of reflexes (hyporeflexia)
- Muscle wasting and atrophy
Red flags for identifying serious conditions like malignancy
- History of cancer
- Unexplained weight loss
- Age>50
Red flags for identifying serious conditions like spinal fracture
- Major trauma
- Minor trauma or strenous lifting in older/osteoporotic individuals
- Prolonged corticosteroid use
- Osteoporosis
- Adv age > 70
Red flags for identifying serious conditions like infection
- Constitutional symptoms (fever, chills)
- Recent bacterial infection (urinary tract or skin infections, pneumonia)
- Immunosuppression
- Intravenous drug abuse.
For lumbar strains,
What is the history?
What is the etiology?
What is found on exam?
What is treatment?
Lumbar strain
History: Axial low back pain after acute injury like lifting or twisting;pain worse with movement;better with rest
Etiology: Muscle disruption from excessive stretch or tension
Exam: localized muscle tenderness/reduced ROM/Normal neuro exam
Treatment:
Relative rest
Pain control with NSAIDS, muscle relaxants
Physical therapy if >4 weeks or recurring
Majority self limited
Radiculopathy, nerve root impingement
What are the most affected nerves in cervical spine and lumbar spine?
Cervical spine: C6, C7 most affected
Lumbar spine: L5, S1 most affected
What are the pathophysiologies of radiculopathy?
Mechanical compression of nerve root
- Neural ischemia, increased intraneural pressure
- Edema of nerve root, DRG
- Dura is mechanically sensitive
Biochemical irritation of nerve root
- Nucleus pulposis contains cytokines, leukotrienes, cox2,interleukin1, tnf-alpha
- Can cause apoptosis of DRG cells
For Disc Herniations, what is the history?
Acute injury/event or more insidious. Limb pain>axial spien pain
numbness/tingling/weakness may or may not be present
Worse: lumbar- sitting, bending, cough/sneeze
Cervical- ROM
Better: lumbar- standing, walking
Cervical-lying
What are exam findings for disc herniations?
Myotomal weakness
Dermatomal pain/numbness/tingling
Decreased or absent reflex of affected nerve
Spurling or SLR positive
What are the typical treatments for disc herniation?
Activity modification-avoiding bedrest
Pain medication: NSAIDs, neuromodulators, short course oral prednisone, limited opioids
Physical therapy
Epidural steroid injection for pain control
*Surgical discectomy possible but 70-85% improve w/out
What indications are there for discectomies in disc herniations?
Progressive or profound weakness
Refractory symptoms
Bowel/blader dysfunction
Myelopathy
What is Ankylosing Spondylitis presentation early and late?
Early Ankylosing Spondylitis:
- Widening of the sacroiliac joints with adjacent sclerosis compatible with sacroilitis
- There is posterior longitudinal ligament sclerosis at L1-L2, L2-L3
Late Ankylosing Spondylitis:
- Fusion of both sacroiliac joints compatible with advanced sacroilitis
- Symmetric syndesmophytes bridging all vertebral bodies resulting in a bamboo spine
- Ossification of the anterior, posterior, and interspinous longitudinal ligaments
What is Ankylosing spondylitis?
A chronic inflammatory disease with progressive involvement of sacroilac and axial skeletal joints. Also w/ enthesitis as well as chondritis and osteitis
For Ankylosing Spondylitis
- Systemic effects?
- History?
- Exam?
- Labs?
- Treatment?
Systemic effects
Upper lobe interstitial lung fibrosis
Iritis
CV abnormalities (aortitis, aortic insuff, cardiomegaly, conduction defects)
History
Slowly progressive low back pain and stiffness. Worse in morning and with prolonged inactivity, better with exercise.
Exam
Reduced lumbar ROM, tender over SI joints, SI joint provocative tests positive. otherwise unremarkable
Labs
Elevated C-reactive protein, sedimentation rate. 90% HLA-B27 positive
Treatment:
NSAIDs/Physical therapy/Anti-TNF-alpha agents if severe and refractory to NSAIDs
What is spondylolysis and spondylolisthesis
Fracture of PARS lamina with no slippage of adj articulating vertebrae (most common L5-S1)
versus
bilateral defect with complete dislocation w/anterior displacement of the L5 body and transverse process.
What is the
History
Etiology
Exam
Treatment
For Facet joint arthropathy
For Facet joint arthropathy
History: Axial low back pain, gradual onset.
Cervical worse with cervical extension, lumbar worse with standing/walking (better sitting/lying)
Etiology: Gradual degen/osteoarthritis to zygoapophyseal (facet) joints. These are synovial joints and this becomes common >55
Exam: Nonspecific, pain provoked with active extension, relieved with flexion
Treatment: Imaging, NSAIDs, Physical therapy, Facet joint steroid injections if refractory
For Lumbar stenosis
History
Exam
Etiology
Treatment
History: Slowly progressive pain in back and uni or bilateral legs (worse when standing/walking, relieved with lumbar flexion, sitting)> Usually >55 yo
Exam: No focal findings, neural exam normal
Etiology: Narrowing of the spinal canal
Treatment: Physical therapy, gait aid, NSAIDs, Epidural steroids, Surgical if intolerable pain
What is the most common cause for compression fractures?
Osteoporosis
Assoc. with prolonged coritcosteroid use. However if <55 yrs then consider underlying malignancy such as multiple myeloma.
For compression fractures
History
Exam
Labs
Treatment
History:
Sudden onset of thoracic or lumbar pain
Can be related to trauma/fall/heavy exertion, or not.
Worse with flexion and movement
Better with rest.
Usually no leg pain or tenderness.
Exam:
Local tenderness,
painful lumbar ROM (especially flexion),
normal neuro
Treatment
Imaging: plain xrays or maybe MRI or CT
If malignancy suspected: CBC, SPEP, alkphos, ESR
NSAIDs, acetaminophen, calcitonin, mild opioids
Bracing x6 weeks
Osteoporosis workup (DEXA scan, endocrine w/u)
For Caudal Equina Syndrome
History
Etiology
Exam
Treatment
For Caudal Equina Syndrome
History:
Back pain
Leg pain (numbness, weakness)
Saddle anesthesia
Bowel or bladder dysfunction (urinary retention most common)
Etiology: Large herniated disc compressing cauda equina most common (can also be epidural tumor/abcess/hematoma)
Exam: Reduced or absent reflexes, weakness, decreased rectal tone
Treatment: Surgical emergency
Findings from exam for Cervical Myelopathy
- UE and LE w/ predom upper motor neuron findings and weakness below level of cord involvement (Hyperreflexia in upper and lower limbs, Hoffman’s sign/positive babinski, ankle clonus)
- Lhermitte sign
- Romberg sign
- Wide base, ataxic, shuffling, slow gait
Etiology for Cervical myelopathy
Spinal cord compression
Usually gradual progression due to posterior osteophyte formation, spinal stenosis
(can also occur due to tumor, abcess, hematoma, and other cord compressive lesions)
Treatment for Cervical Myelopathy
Surgical treatment for cervical decompression (laminectomy), may not correct neuro deficits but will prevent progression.
