Spinal Flashcards
how many vertebrae
33
how many:
- cervical
- thoracid
- lumbar
- sacral/coccyx
7 cervical
12 thoracic
5 lumbar
9 sacral/coccyx
what is the natural curvature of the neck
cervical lordosis aka anterior curve
what is the natural curvature of thoracic spine
posterior curve aka thoracic kyphosis
natural curve of the lumbar
lumbar lordosis aka anterior curve
what is normal order of curvature from head to tailbone
Lordosis
Kyphosis
Lordosis
what bears 80% of load
anterior arch–>vertebral body/discs
whats in the anterior arch
vertebral bodies/discs
takes 80% of weight load
pedicle
nerve roots
-area b/w body and transverse processes
whats in the posterior arch
takes on 20% of weight
- pedicle
- transverse process
- superior and inferior articular processes
- lamina
- vertebral foramen
what is lamina
thin, plate like area b/w spinous and transverse processes
what runs thru vertebral foramen
vasculature
spinal cord
radicular pain
pain + numbness + tingling
what can we use to figure out what spinal root nerve has a problem
dermatome
dermatome
cutaneous area supplied by a single spinal nerve root
**used to figure out which sensory deficit goes with which nerve root
C _ _ and _ keep the ___ alive
C 3, 4, 5, keeps the diaphgram alive
C5 dermatome
-what does nerve control
covers the outer part of the upper arm down to about the elbow
**deltoid
C6 dermatome
-what does nerve control
covers thumb side of the hand and forearm
**control the wrist extensors (muscles that control wrist extension) and also provides some innervation to the biceps
C7 dermatome
-what does nerve control
goes down the back of the arm and into the middle finger
**control the triceps (the large muscle on the back of the arm that straightens the elbow) and wrist extensor muscles
C8 dermatome
-what does nerve control
pinky side of the hand and forearm
**helps control the hands, such as finger flexion (handgrip)
L3 dermatome
front part of the thigh and inner part of the leg
L4 dermatome
parts of the thigh, knee, leg, and foot
L5 dermatome
parts knee, leg, and foot
S1 dermatome
posterolateral thigh and leg and the lateral foot
S2 dermatome
strip of skin along the back of the thigh and the upper calf
***medial aspect
spinal stenosis
- what is it
- MCC? other etiologies (4)
- MC in who
- s/s
- what makes s/s worse, better
- Diagnostic test of choice
- management
*narrowing of the spinal canal with impingement of the nerve roots
MCC by:
- degenerative arthritis
- spondylolysis
Other etiologies:
- post-surgical
- congenital
- traumatic
- inflammatory
MC in:
*adults over 60
S/S
- back pain
- numbness + paresthesias–>rad to buttocks & thighs bilaterally
S/S WORSE W/:
*extension: prolonged standing, walking upright, walking downhill
S/S BETTER W:
- flexion: sitting, leaning forward (over shopping cart), walking uphill, cycling
- lumbar flexion increases canal volume*
TOC=MRI
Management: *Pain control *PT-->cycling, swimming *steroid injections *surgical= decompression laminectomy ******surgery only for refractory or severe cases*****
Ankylosing Spondylitis
- what is it
- what joints are affected
- RFs (2)
- S/S
- labs
- imaging–initial test? most accurate?
- tx
Ankylosing=stiffness of joints due to FUSION of joints
- *chronic inflammatory arthropathy of axial skeleton
- **spine + sacro iliac joints + progressive spine stiffness
RF:
- HLA-B27 positivity
- young males 15-30 YO
S/S:
- back pain + stiffness + decr ROM–>worse in the am or rest
- Kyphosis, Sacroilitis ** and large joint arthritis
- Extrarticular: Achilles tendon enthesitis, dactylitis, **Uveitis,
- cardiac: AV blocks, aortic regurg,
- pulm: fibrosis, decr chest expansion
LABS:
- increased ESR
- negative rheumatoid factor
- negative ANA
IMAGING:
- XR of SI joints is initial test
* *shows sacroiliitis (narrowing of the joint) –>early finding - bamboo spine: straightening of the spine (loss of normal lumbar curvature) + squaring and fusion of the vertebrae–>later findings
- MRI= most accurate test
MANAGEMENT:
- first line: NSAIDS + exercise + PT
- second line: Anti-TNF drugs if no resp to NSAIDS
- –>Etanercept
- –> Adalimumab
- –> Infliximab
Herniated Disc aka Nucleus Pulposus
- MC where
- S/S: pain incrs with?
- PE findings
- Diagnosis: TOC imaging?
- TX: first line, 2nd line or worsening,
MC L5-S1
S/S:
- Radicular back pain
- unilateral
- rad down the leg w/ paresthesias or numbness in dermatomal pattern
-pain INCRS with: coughing, straining, bending, sitting, Valsavla
PE
- (+) straight leg raise
- next: figure out which disc is the problem
DIAGNOSIS:
- MRI is TOC
- XR: will see loss of disc height
TX:
- first line=conservative
- -> NSAIDs + continuation of ordinary activities as tolerated
- **if bed rest, should be brief
- PT
- more severe: muscle relaxers or oral steroids
*Corticoid injections if conservative tx fails (aka pain does not improve at all in two weeks OR it gets worse)
- surgical tx:
- ->laminectomy & discectomy if persistent, disabling pain >6 weeks not responding to other tx
where is the junction b/w the mobile and non-mobile spine
-MC spot for?
L5-S1
**MC spot for herniated disc
explain straight leg raise test
(+) finding means?
raising leg–>positive pain after 30 degrees but before 70 degrees
dont ask if this hurts and raise leg*
**INSTEAD: ask them, tell me when the pain starts hurting as you move leg upwards
straight leg test reveals:
-anterior thigh pain with sensory loss to the medial ankle–>weak ankle dorsiflexion + loss of knee jerk
-l4 disc herniation
straight leg test reveals:
- lateral thigh/leg and dorsum of foot pain
- weak big toe extension
- walking on heels more difficult than on toes
- normal reflexes
L5 disc herniation
straight leg test reveals:
- posterior leg/calf and plantar surface of foot
- weak plantar flexion=walking on the toes is more difficult than on heels
- loss of ankle jerk
S1 disc herniation
compression fx
- aka
- occur?
- s/s
- diagnosis
burst fx
*occur: from jumping/falling from a great height, also can occur in elderly or bc of CA—- called pathologic lumbar compression fxs
S/S
*localized back pain with focal midline tenderness at level of fx
Diagnosis
- xrays: loss of vertebral height
- MRI or CT is neuro s/s
TX
- orthopedic & neurosurgery consult to determine appropriate workup and management
- conservative: observation, analgesics, bracing with gradual return to activity
- surgical: kyphoplasty may be used if s/s are severe or persistent
Spondylolysis
- define
- due to?
- MC where
- MOA
- CM
- MC in who
Pars interarticularis defect due to failure of fusion or stress fx
- MC at L5-S1
- MOA: repetitive hyperextension trauma (football players, gymnasts, weight lifters
CM
- most cases asymptomatic
- low back pain with activity—-MC in kids and adolescents
DIAGNOSIS
- xray: lateral views: radioluscent defect in pars
- CT scan
- bone scan
TX
1. low-grade or asympto: observation, no activity or restriction
- Sympto: PT and activity restriction in some PTs
- Bracing may be helpful for acute pars stress reaction or failed PT
Spondylolisthesis
- what is it
- MOA… MC? other causes
- CM.. MC?
- diagnosis
- Forward slipping of a vertebra on another–>bilateral fracture or defect of the pars interarticularis
- MOA: usually a complication of spondylolysis
- other causes: trauma, malignancy, congenital anomilies
CM
- most are asympto
- lower back pain MC symptom
- nerve compression: sciatica, bowel or bladder dysfunction and neurologic deficits if severe
DIAGNOSIS:
- xray: forward slipping of a vertebra. LATERAL views: used to measure slip angle and grade
- MRI: if neuro s/s present
TX
- mild: tx like spondylolysis–PT, activity restrction in some cases
- severe: cases may need surgical intervention
spondylolysis vs spondylolisthesis
spondylolysis–>defect of pars interarticularis from stress fx or failure to fuse—scottie dog sign–lumbar oblique projection–mc L5-S1
spondylolisthesis—>forward slipping of the vertebrae on another + bilateral fx or defect of pars interarticularis
Cauda Equina Syndrome
- define
- where does SC end
- where does cauda equina start and end
- role of cauda equina
- MCC and other causes
- CM
- diagnosis—toc
- tx
- mix of s/s that occur bc of spinal nerve compression in lumbosacral region
- SC ends at L1 ad L2–>cauda equina aka horses tail starts BELOW and goes from L2-S5
- cauda equina carries motor and sensory nerves and innervates bladder
MCC=lumbar disc herniation
Other causes: spinal inj, tumor, trauma, epidural abscess, epidural hematoma, vertebral fx
EMERGENCY— call ortho/surgery/neuro IMMEDiATELY **
CM
- back pain PLUS any ONE of the following:
1. radiculopathy: BILAT leg radiation of pain, weakness in multiple root distributions (L3-S1)
2. Involvement of S2-S4 spinal nerve roots: SADDLE ANESTHESIA–>decr sensation to buttocks, perineum and inner surfaces of the thigh—-ED too!
3. New onset urinary or bowel retention OR incontinence
4. Decr anal sphincter tone on PE
DIAG
- MRI toc
- if MRI contra (ex pt has pacemaker)—CT
TX—CALL ORTHO/SURGERY/NEURO ASAP
- emergent decompression
- Corticosteroids to reduce infalmm
anterior thigh pain; weak ankle dorsiflexion; loss of knee jerk
L4 herniation
s/s for L4 herniation
- anterior thigh pain
- weak ankle dorsiflexion
- loss of knee jerk
lateral thigh/leg and dorsum of foot pain; weak big toe extension. Walking on heels more difficult than on toes. Reflexes normal
L5 disc herniation
s/s for L5 disc hern
- lateral thigh/leg and dorsum of foot pain
- weak big toe extension
- walking on heels more diff than toes
- reflexes normal
posterior leg/calf and plantar surface of foot; weak plantar flexion = walking on the toes is more difficult than on heels. Loss of ankle jerk
s/s of S1 disc hern
s/s of S1 disc hern
- posterior leg/calf and plantar surface of foot pain
- weak plantar flexion
- walking on the toes is more diff than heels
- loss of ankle jerk
