Scoliosis and Low Back Pain

Question 1

Scoliosis

Answer 1

lateral curve of the spine great than 10 degrees with vertebral rotation

classified as congenital, neuromuscular, or idiopathic
*most are idiopathic

adolescent idiopathic scoliosis is the most prevalent

Question 2

Risk factors of Scoliosis

Answer 2

female more likely to progress to sever scoliosis

hereditary: if both parents have AIS: kids are more likely to require tx than general population

Question 3

Screenings

Answer 3

Negligible risk to patients

-radiographs and referrals: increase expense and risk of harm

Question 4

Adolescent Idiopathic Scoliosis: Screening

Answer 4

Children aged 10-18

Treatment is determined by the degree of spinal curvature

Question 5

Clinical Presentation of Scoliosis

Answer 5

diastematomyelia: congenital splitting of the spinal cord
Syringomyelia: cavity in the spinal cord
Tethered cord
Spinal tumors--cause spinal curvature
neurofibromatosis
unilateral cavus food

Question 6

Physical Exam for Scoliosis

Answer 6

body tires to keep eyes level
shoulder height difference
posterior scapula
crease at waist

Adam forward bend test
*leg lengths are usually equal

Question 7

Adam’s Forward Bend Test

Answer 7

bends forward at the waist with examiner assessing from symmetry

-possible scoliosis-lateral bending of the spine, curve will cause spinal rotation and rib hump will be visible on examination

Question 8

Scoliometer

Answer 8

quantify the spinal curve and rotation…does the spine need radiography?

Radiography: Cobb angle greater than 10 degrees

Question 9

Risser Sign-Progression Prediction

Answer 9

defined by the amount of calcification present in the iliac apophysis and measures the progressive ossification from anterolaterally to posteromedially

Question 10

Red Flags for scoliosis

Answer 10

1. onset before age 8
2. severe pain
3. unusual left thoracic curve
4. neurologic deficits or findings (midline hairy patch)
5. rapid curve progression: 1 degree per month

Question 11

ROS for Scoliosis Important

Answer 11

left curve associated with additional pathology

-spinal cord tumors, neuromuscular disorders, chiari malformation

Question 12

Scoliosis Exam

Answer 12

• lateral curve of spine greater than 10 degrees with vertebral rotation
• adams forward bend or scoliometer
• right or left curve
• neuroexam, skin exam, imaging when necessary

Question 13

Management of a curve less than 10-15 degrees

Answer 13

no active treatment and can be monitored

Question 14

management of a curve between 25-45 degrees in patients lacking skeletal maturity

Answer 14

used to be treated with bracing, but this tx hasn’t been proven to prevent curve progression

Question 15

management of a curve more than 45 degrees

Answer 15

rod placement and bone grafting

Question 16

Treatment for Scoliosis

Answer 16

Bracing

• halt progression of curve that is between 20 and 45 degrees
• not effective for large curves

Milwaukee brace
Boston brace–apex of curve must be below T10
Charleston Nighttime brace

Question 17

Milwaukee Brace

Answer 17

used for scoliosis
20-40 degree curves
used with growing patients

Question 18

Boston Brace

Answer 18

works on a multitude of deformities (lordosis, rotation, soliosis)

**apex of curve must be below T10

Question 19

Charleston Nighttime Brace

Answer 19

worn only at night….sB patient into the curve

“as effective as 24 hour brace”

Question 20

Surgical Option for Scoliosis

Answer 20

adolescents with curve greater than 40 degrees require definitive tx
pulmonary compromise starts at curves greater than 50 degrees
cardiac compromise with 75+degrees

• -posterior spinal fusion
• -Harrington Rods

Question 21

What is concerning for PE for scoliosis?

Answer 21

LEFT CURVE IS WORSE THAN RIGHT

Question 22

left curve scoliosis

Answer 22

don’t tx as conservatively

Question 23

Evaluation of Low Back Pain

Answer 23

5th most common reason for dr visits

most are self limiting and resolve with little intervention

Question 24

Acute Low Back Pain

Answer 24

defined as 6-12 weeks of pain between the costal angles and gluteal folds that may or may not radiate

Question 25

Differential Dx for acute low back pain

Answer 25

``` compression fracture herniated disc lumbar sprain/strain spinal stenosis spondys CT disease: multiple joint arthralgias Inflammatoy spondyloarthropathy Malignancy: pain worsens in the prone position AAA GI conditions (pancreatitis) Herpes Zoster Pelvic Conditions: discomfort in lower abdomen ```

Question 26

Red Flags with Low Back Pain

Answer 26

- Cancer - Cauda Equina Syndrome: bowel and bladder incontinence - Fracture - Infection: severe pain and lumbar spine surgery within past year, IV drug use Trauma, unexplained weight loss, neurologic symptoms, age above 50, fever, IVDU, Steroid Use, History of Cancer

Question 27

Back Strain: SD of Lumbosacral Spine

Answer 27

``` mild trauma --usually twisting described as muscle ache or spasm strain may become chronic discrete TP of lumbar tissue no neurological deficits ```

Question 28

Psoas Syndrome

Answer 28

Flexion Contracture initiated by psoas, sitting, bending, getting up quickly from squatting position, desk jobs may refer to the groin +thomas test TP medial to ASIS

Question 29

Herniated Nucleus Pulpous

Answer 29

herniated disc in lumbar region that will exert pressure on the nerve root of the vertebrae below - pain in lumbar radiates to foot - sharp burning pain - weakness in affected myotome (decreased reflexes) - most treated conservatively

Question 30

How to Dx Herniated Nucleus Pulpous

Answer 30

MRI

Question 31

Radiation Patterns

Answer 31

spine structures: thigh region SI joint: thigh and below the knee Lumbar root: more leg pain than back pain L1-L3 nerve roots: radiate to hip/knee thigh L4-S1: pain radiates below the knee

Question 32

Where do most herniations occur?

Answer 32

L4/L5 | L5/S1

Question 33

L1-L3

Answer 33

radiates to hip and or thigh

Question 34

L4-S1

Answer 34

radiates below the knee

Question 35

Cauda Equina Syndrome

Answer 35

lateral central disc herniation compressing the tail of the lumbar spine causing compression of sacral nerve roots impingement of S2-S4 causes bowel and bladder dysfunction, decreased rectal tone, saddle anesthesisa **Emergent, surgery is imperative

Question 36

Spinal Stenosis

Answer 36

narrowing of the space around the spinal cord pain originates in lower back and radiates down the leg pain worsened w/ standing, walking, laying supine

Question 37

Spondylolysis

Answer 37

"Collar of Scotty Dog" | fracture of pars interartcilaris

Question 38

Spondylolisthesis

Answer 38

vertebral body slips in relation to the one below at pars interarticularis L5 and S1 pain worse with standing + step off sign with lumbar palapation

Question 39

L5/S1

Answer 39

plantar flex sensory to posterior leg and lateral foot achilles reflex Toe Walk

Question 40

L4/L5

Answer 40

Dorsiflex the great toe lateral leg and dorsal foot reflex: medial hamstring Heel walk

Question 41

L3

Answer 41

Hip Flexors Sensory: anterior/medial thigh patella

Question 42

L4

Answer 42

knee extension sensory: anterior leg with medial foot patella reflex

Question 43

Imaging for Low Back Pain

Answer 43

dont image within the first 6 weeks unless red flags are present (neurological deficit or osteomyelitis)

Question 44

Treatment for Nonspecific Acute Low Back Pain

Answer 44

Bed rest is not helpful NSAIDS and muscle relaxants patient education: Stay active PT

Question 45

History/ Risk Factors

Answer 45

``` age level of trauma job/hobby IVDU Steroid Use HX of Cancer ```

Question 46

ROS for Back Pain

Answer 46

fever? weight loss? Neuro symptoms--bowel and bladder dsfxn?