Scoliosis and Acute Low Back Pain

Question 1

What is Scoliosis?

Answer 1

lateral curve of the spine greater than 10 degrees wit vertebral rotation

Question 2

Classification of Scoliosis?

Answer 2

Idiopathic (meaning “we don’t know”) - 85% of cases

adolescent is most common so

Adolescent Idiopathic Scoliosis (AIS) most common

Question 3

What’s the difference in sexes and scoliosis, including minor and severe?

what about kids and their parents having it?

Answer 3

of the 2-4% that have it, it’s equal M=F for having minor scoliosis

but Females are 5-10x as likely to progress to severe disease

if both parents have AIS, kids are 50x more likely to get treatment.

Question 4

what’s to note about the risk of screening kids for scoliosis? what presents with a higher risk?

what does the USPSTF report?

Answer 4

when you screen kids, the risk of screening is pretty small.

you pretty much have them bend forward, touch their toes, and look at their back.

the problem is if we find if that’s abnormal, we do X-rays and referrals and treatment… that may have moderate harms (cost, discomfort, etc)

they report that most cases detected through screening do not progress to clinically significant scoliosis… scoliosis that requires surgery likely to be detected without screening (come in before that to complain about it).

Question 5

What do kids present with that have been referred from screen-based screening programs?

Answer 5

AIS (adolescent idiopathic scoliosis)

Diastematomyelia (congenital splitting of the spinal cord)

Syringomyelia (cavity in the spinal cord)

tethered cord

tumors

neurological symptoms

etc

Question 6

When should you be suspicious during a physical exam for scoliosis?

Answer 6

body tries to keep eyes level

shoulder height difference

you see the posterior scapula

crease at the waist

Question 7

What is the Adam’s forward bend test

Answer 7

have the patient bend forward at the waist.

they’ll have lateral bending of the spine, but the curve will cause spinal rotation and eventually a rib hump!

Question 8

What is a Scoliometer?

what is the angle that would mean if it was

AIS and Cobb angle measurements?***

Answer 8

It’s a level used to determine who needs radiography

you put the scoliometer on the back of a bending over patient

AIS evaluation is based upon the angle of the trunk (ATR) being greater than 7 degrees

and the Cobb angle greater or equal to 10 degrees

Question 9

How do you do the Cobb angle?

Answer 9

you measure the angle of scoliosis through the radiography

Question 10

Risser sign?

Answer 10

It tells you how skeletally mature a person is and if you have a chance to worsen because your skeleton isn’t fused completely yet

the amount of calcium formation present in the iliac apophysis and measures the progressive ossification from anterolaterally to posteromedially.

from 1-5

grade 1 means 25% ossification to grade 5.. which is 100%

Grade 5 means the iliac apophysis has fused to the iliac crest after 100% ossification.. so you don’t expect them to get worse

Question 11

8 year old with Risser sign grade 1. what’s the likelihood they’re going to worsen?

this vs a 12 year old with risser sign 5

Answer 11

the likelihood is greater for the kid who hasn’t developed yet than to the twelve year old with completely fused bones. the fused bone doesn’t have much more to grow

Question 12

What are the 5 red flags for scoliosis?

Answer 12

onset before age 8

severe pain

rapid curve progression > 1 degree per month

unusual Left thoracic curve (convex to the left)

neurological deficits or findings (midline hairy patch, cafe au lait spots)

Question 13

Management for people less than 10-15 degrees scoliotic curve?

Answer 13

no active treatment, but keep an eye on patients likely to progress ( Risser sign)

Question 14

25-45* and management for scoliosis?

above that?

Answer 14

bracing, but hasn’t been proven.

surgery

Question 15

Milwaukee brace?

Answer 15

23 hours/day

Question 16

Charleston nighttime brace?

Answer 16

just as effective as the Milwaukee brace, but only worn at night.

Question 17

at 50 degrees, what are you preventing?

75?

what surgical stuff do they do?

Answer 17

pulmonary compromise

cardiac compromise

posterior spinal fusion and Harrington rods

Question 18

What is the definition of acute low back pain?

what kind of specificity if acute low back pain?

Answer 18

6-12 weeks of pain b/t the costal angles and gluteal folds that may radiate down one or both legs (sciatica)

nonspecific (meaning not significant from a medical emergency)

Question 19

cauda equina syndrome?

Answer 19

bladder or bladder incontinence, urinary retention, motor or sensory loss (saddle anesthesia too!)

Question 20

what are the red flags of history and exam for back pain?

Answer 20

TUNA FISH

Trauma
Unexpected Weight loss –> cancer

Neurological symptoms –> cauda equina

Age greater than 50 –> prostate cancer

Fever –> infection

IVDU –> infection

Steroid Use –> osteoporosis and fractures, reduces immune system

History of Cancer –> focal spinal pain

Question 21

Somatic Dysfunction of Lumbosacral spine (back strain)?

Answer 21

this is just mechanical back pain

usually starts with mild trauma, especially twisting!

described as muscle ache or spasm

strain may be chronic

Question 22

Psoas Syndrome?

what is it initiated. by?

what kind of pain do they have?

where are the tenderpoints?

what test is going to work to confirm?

Answer 22

shortening/spasm of the iliopsoas muscle

Initiated by positions that shorten the Psoas.. sitting, bending, getting up quickly from squatting, desk jobs.

dull ache in low back, sometimes refers to groin

tender points at the Iliacus (medial to ASIS)

Thomas Test

Question 23

Sacroiliac/piriformis syndrome?

Answer 23

irritation on the piriformis pinches down on the sciatic nerve.

gives you pain down your leg

“wallet sign”

Question 24

Herniated disc (nucleus pulposus)

where does the pain go usually?

what type of pain?

+ test?

Answer 24

Herniated disc in the lumbar region will exert pressure on the nerve root of the vertebrae below

often radiates from lumbar spine to radiating down the leg.

sharp/burning pain.

+ Straight Leg Raise

Question 25

What is the gold standard for Herniated Nucleus Pulposus?

Answer 25

MRI

Question 26

98% of herniations occur where?

what nerves are impinged?

Answer 26

between L4 –> L5 and L5 –> S1

the lower one. so

Question 27

If someone has S1 impinged, meaning L5/S1.. what physical exam findings would you find?

Answer 27

Achilles tendon wouldn’t go

Question 28

Cauda Equina Syndrome?

how emergent is this?

Answer 28

large central disc herniation that impinge on nerves S2-4 which cause bowel/bladder dysfunction, decreased rectal tone, saddle anesthesia

emergent surgery is needed otherwise irreversible paralysis.

Question 29

Spinal Stenosis?

what symptoms will they have in their legs? time of day?

what will you see on X-rays?

Answer 29

narrowing of the space around the spinal cord

Leg symptoms –> pain, numbness, weakness

Pain worsened by standing, walking, lying supine (all the time)

degenerative spondylosis, narrowing of the disc/foramina, osteophytes

Question 30

What is a Spondylolysis?

what will you see?

Answer 30

Collar of Scotty Dog.. usually at L5/S1

Question 31

Spondylolisthesis?

where is it usually?

where do you have pain?

what differentiates this from spondylolysis

Answer 31

vertebral body slips in relation to the one below

usually L5/S1

back pain radiating posterior to or below the knee

you’ll see a “Step off” –> this is how you differentiate spondylolysis or spondylolisthesis!

Question 32

If you have them walk on their heels, what are you testing?

Answer 32

L5..

if they can’t do that, it’s an abnormal finding. you’re looking at L4/L5 herniated disc.

Question 33

if someone has mechanical low back pain, what do you do?

Answer 33

wait 6 weeks then do an XRay

Question 34

for nonspecific low back pain, what is not helpful?

Answer 34

staying in bed! it doesn’t help.

Question 35

ROS, what are you looking for for low back pain?

Answer 35

Fever/Wt loss

neurological symptoms - bowel/bladder functions

Question 36

someone has spondylolisthesis.. what’s the treatment first step

Answer 36

flexion exercises and avoiding what aggravates it

Question 37

what’s worse, a left or right scoliotic curve?

Answer 37

left.. that’s associated with pathologies!

Question 38

treatment for spondylolisthesis?

Answer 38

flexion exercises