Spinal Column Disorders

Question 1

Cervical Strain

Answer 1

● Although the term “strain” generally refers to injury of
muscle tissue, the term “Cervical Strain” includes
ligamentous injury of the facet joints and/or
intervertebral disks, in addition to muscle injury.
○ “Neck sprain” is synonymous

Question 2

Common etiology of cervical strain

Answer 2

whiplash injury

Question 3

Cervical Strain pathophysiology

Answer 3

○ Whiplash injuries occur with rapid
acceleration and/or deceleration,
which results in rapid flexion and
extension of the cervical spine.
○ The velocity of the movements can
stretch and tear muscles, disrupt
ligaments, dislocate facet joints, and
cause spinal fractures.
○ Cervical instability can develop.

Question 4

Cervical Strain Clinical Presentation

Answer 4

○ Cervical pain that begins after an accident or trauma, but can start spontaneously (even during sleep).
○ The pain does not radiate into the arms or down the spine.
○ Diffuse pain anywhere from the base of the skull to the cervicothoracic junction is most common.
○ Pain is often increased with motion and may be accompanied by muscular spasm in the sternocleidomastoids, trapezius muscles, or paraspinals.
○ Occipital headaches may occur and may persist for months

Question 5

Cervical Strain PE

Answer 5

○ Exam may reveal tenderness to palpation of the sternocleidomastoids,
trapezius muscles, or paraspinals secondary to muscle spasm.
○ Tenderness may be noted over the spinous processes and facets

Question 6

Cervical Strain diagnosis

Answer 6

○ Pain often limits range of motion.
○ The neurologic examination should be normal
■ No Lhermitte’s sign (electrical pulse through body with neck flexion)
■ No Spurling sign (radiating pain down arm with lateral bending)
■ No pain or paresthesias into the arms or down the spine AP, Lateral, and Odontoid (open-mouth) X-rays should be obtained if there is a history of trauma, associated neurologic symptoms, or if the patient is elderly
○ If severe pain, Flexion and Extension films (aka
Flex/Ex films) should be obtained, but should be
ordered by a consulting specialist

Question 7

Cervical Strain Managemen

Answer 7

○ Most patients return to normal within 4-6 weeks
○ Acetaminophen and NSAIDs are preferred, although a short course (no
more than 1 week) of narcotic may be needed.
○ 1-3 weeks in a Soft Cervical Collar is often beneficial.
○ 1-2 weeks of Muscle Relaxants can be beneficial.
○ Manipulation of the cervical spine is contraindicated
in patients with acute cervical spine injuries!

Question 8

Acute Low Back Pain

Answer 8

● Acute LBP is more of a symptom than a diagnosis. However, 80%+
of LBP patients are not able to be given a more specific diagnosis.
○ Acute = LBP of less than 3 months in duration.
● Lifetime prevalence in the US is 60-80%.
● Of all cases of acute LBP, 70% are secondary to
lumbar sprain or strain

Question 9

Acute Low Back Pain pathophuysiology

Answer 9

○ Lumbar strain is an injury to the paravertebral
spinal muscles.
○ Lumbar sprain refers to ligamentous injury of
the facet joints or annulus fibrosus,
transvertebral or other spinous ligaments.
○ Age-related facet or vertebral arthropathy can flare if provoked acutely by certain movements or lifting

Question 10

Acute Low Back Pain presentation

Answer 10

○ Patients often report an acute onset of LBP after lifting or twisting
○ Low back pain may radiate down into the buttocks.
○ Even though lifting or twisting is a common
cause, patient who are sedentary also
frequently experience LBP (poor fitness,
sitting at computer).
○ May have difficulty standing up straight
and transitioning from position to position.
○ Patients often have diffuse tenderness to palpation in the lumbar region and/or sacroiliac area
○ Lumbar range of motion is often decreased
secondary to pain.

Question 11

Acute Low Back Pain diagnosis

Answer 11

○ The goal is to identify the serious causes of low back pain and know when it is necessary to order radiologic imaging.
○ Because most have strain or sprain, plain X-rays are usually not helpful and need not be ordered for all cases of LBP
○ If significant pain at rest, pain at night, or history of trauma,
ordering X-rays (AP and Lateral) would be appropriate.

Question 12

Acute Low Back Pain management

Answer 12

○ As long as the patient has no sciatic symptoms or significant neurologic deficit,
treatment of acute LBP (most commonly strain or sprain) has 2 phases:
“Essentials of Musculoskeletal Care,” 5e. Armstrong, Hubbard.
■ Phase 1- Focus on Symptomatic Relief
■ Phase 2- Focus on Return to Activity

Question 13

Chronic Low Back Pain

Answer 13

● Chronic LBP is defined as LBP that lasts for 3+ months.
● Symptoms are most commonly recurrent and episodic,
but for some the pain is unrelenting

Question 14

Once Chronic LBP has been identified, a thorough evaluation should occur, ruling out the following:

Answer 14

○ Cancer (metastatic or primary)
○ Osteoporosis with fractures
○ Osteomyelitis and discitis (infection)
○ Abdominal pathology (aneurysm, retroperitoneal tumor)

Question 15

Chronic Low Back Pain pathophysiology

Answer 15

○ The most common cause of Chronic LBP is
degenerative disc disease.
○ Other causes include:
■ Lumbar stenosis
■ Ankylosing Spondylitis
■ Old vertebral fractures

Question 16

Chronic Low Back Pain clinical presentation

Answer 16

○ Chronic low back pain that radiates to one or both buttocks.
○ Pain is aggravated by activity (lifting, bending, twisting, etc).
○ Patient may have history of intermittent sciatica (radiating down the back of the leg), but back pain is the predominant symptom.
○ Rest helps to relieve the pain for most patients.
■ Some have difficulty sleeping because of the back pain
○ Progressively worsening back pain with weight loss is a red flag for cancer and should not be ignored

Question 17

Chronic Low Back Pain evaluation

Answer 17

○ On examination, there may be diffuse
tenderness to palpation in the lumbar and
sacroiliac regions
○ Neurologic exam of the LEs should be normal.
○ Range of motion may be restricted.
○ X-rays (AP and Lateral) will reveal age-related
degenerative changes.

Question 18

X-ray findings of chronic low back pain

Answer 18

■ Osteophytes with decreased disc height
■ May see spondylosis/spondylolisthesis

Question 19

Narcotic abuse or misuse is a large concern in this group

Answer 19

Chronic Low Back Pain

Question 20

Spinal Fractures pathophysiology

Answer 20

○ High-velocity impact, hyperextension,
hyperflexion, or hyper-rotation can all lead
to vertebral fracture
○ If the central canal or neural foramen are
compromised, neural tissue may be injured
(spinal cord or spinal nerves).
○ Osteoporosis and bony metastasis can
result in “insufficiency” fractures.

Question 21

Spinal Fractures clinical presentation

Answer 21

○ Spinal pain is generally severe, even at rest.
○ Other symptoms depend on presence or absence of neural tissue compression
■ Spinal cord damage will result in paresthesias
and loss of motor control below the level of
the injury.
■ Nerve root impingement will result in pain and paresthesias along the associated dermatome (potentially motor loss)

Question 22

Spinal Fractures evaluation

Answer 22

○ Evaluate motor and sensory function throughout all cervical, thoracic, and
lumbar dermatomal/myotomal distributions.
○ Assess deep tendon reflexes for presence and symmetry.
○ Examine for swelling and contusions over the spinal column.
○ Palpate for point tenderness and step-off lesions (posterior ligament injury)

Question 23

Radiologic Imaging of Spinal Fractures

Answer 23

■ Plain X-rays are an option and often reveal the injury.
■ However, if significant trauma or abnormal examination, CT scan is the initial imaging modality of choice in most trauma centers.
● Provides better images with more definitive diagnosis (and faster)
■ MRI is obtained after the CT if there is a concern for neural tissue compression and ligamentous injury

Question 24

Spinal Fractures management

Answer 24

○ If imaging studies reveal no evidence of fracture, and neurologic exam is
normal, spinal precautions may be lifted after confirmation by a
neurologic or orthopedic specialist.
○ If a spinal fracture is identified, urgent consultation by a specialist is
standard of care

Question 25

The three main goals of spinal fracture treatment are:

Answer 25

■ Prevent Neurologic Injury ■ Restore Stability ■ Restore Normal Function

Question 26

Sciatica

Answer 26

● Sciatica is sharp, shooting, radiating pain (sometimes with accompanying paresthesias) that travels through the buttock, down the posterior thigh, past the knee, and into the calf and even foot

Question 27

Common causes of Sciatic compression

Answer 27

■ Herniated Nucleus Pulposus (disc) ■ Lumbar Spinal Stenosis ■ Traumatic Pelvic Fracture ■ Piriformis Syndrome

Question 28

In severe cases of _____, foot drop may be present

Answer 28

sciatica

Question 29

Most cases of unexplained Sciatica resolve with ______

Answer 29

Physical Therapy, rest, and time.

Question 30

Herniated Nucleus Pulposus

Answer 30

● The intervertebral disc is composed of the gel-like Nucleus Pulposus, surrounded by the tough, ligamentous Annulus Fibrosus ● Sometimes the Annulus gives out and the nucleus herniates into the spinal canal.

Question 31

Herniated Nucleus Pulposus pathophysiology

Answer 31

○ Simultaneous twisting and lifting is the most common mechanism of injury, both for cervical and lumbar herniations ○ If significant, local inflammation may lead to localized pain, but more commonly, it’s the neural tissue compression that produces symptoms.

Question 32

C4-5 herniation may result in a ____

Answer 32

C5 radiculopathy ■ Pain and paresthesias in proximal arm, base of neck, possible deltoid weakness, possible loss of bicep deep tendon reflex

Question 33

C5-6 herniation may result in a _____

Answer 33

C6 radiculopathy. ■ Pain and paresthesias in shoulder, radial arm and forearm, thumb and index finger, possible bicep weakness and bicep DTR loss

Question 34

C6-7 herniation may result in a _____

Answer 34

C7 radiculopathy. ■ Pain and paresthesias in the scapula, posterior arm and forearm, including index and middle fingers, possible tricep weakness and loss of tricep DTR

Question 35

L3-4 herniation

Answer 35

L4 radiculopathy. ■ Pain over lateral and anterior thigh, down shin, possibly causing loss of patellar reflex, may involve medial large toe

Question 36

L4-5 herniation

Answer 36

L5 radiculopathy. ■ Pain over lateral thigh, lateral calf, and may cause a foot drop and paralyzed large toe (no associated reflex)

Question 37

L5-S1 herniation

Answer 37

S1 radiculopathy. ■ Pain down posterior thigh and into calf, even bottom of foot and small toe, loss of Achilles reflex and strength

Question 38

Herniated Nucleus Pulposus testing/evaulation

Answer 38

○ Spurling sign may be positive with cervical radiculopathy. ○ Babinski sign, Ankle clonus, Lhermitte sign, and Hoffmann sign may be positive with myelopathy. ○ Straight leg raise is almost always positive with herniated lumbar discs. ○ Assess for deep tendon reflexes.

Question 39

Herniated Nucleus Pulposus imaging of choice

Answer 39

MRI

Question 40

Cauda Equina Syndrome

Answer 40

● Cauda Equina Syndrome occurs when a space occupying lesion compresses ALL of the spinal nerves passing through the thecal sac. ○ Even though it is very rare, it is definitely a “DO NOT MISS” diagnosis

Question 41

Clinical Presentation of Cauda Equina Syndrome

Answer 41

○ Severe pain in bilateral lower extremities ○ Low back pain may be severe as well. ○ Perianal numbness in a saddle distribution is typical and classic (“Saddle Paresthesias”). ○ Disturbance of bowel and bladder control. ■ Overflow incontinence, decreased anal sphincter tone ○ Loss of lower extremity deep tendon reflexes. ○ Lower extremity motor weakness bilaterally

Question 42

Digital rectal exam will reveal decreased anal sphincter tone with _____

Answer 42

Cauda Equina Syndrome

Question 43

Spondylosis

Answer 43

○ A rather broad umbrella term that simply refers to some type of degeneration of a part of the spine. ○ Can refer to arthritis spurs, degenerative discs, ligament thickening, etc

Question 44

Spondylolysis

Answer 44

○ A stress fracture through the pars interarticularis of a lumbar vertebrae. ○ Fairly common and generally secondary to repetitive stress to bone

Question 45

Spondylolisthesis

Answer 45

○ When one vertebrae slips out of position, usually forward over the top of the bone below it. ○ Results from severe spondylosis or due to spondylolysis.

Question 46

X-rays will reveal the so-called “Scotty Dog” sign on oblique films with _____

Answer 46

Spondylolysis

Question 47

Spondylolisthesis presentation

Answer 47

○ Patients with low-grade slips may have little or no symptoms. ○ LBP is the most common symptom and often radiates into the buttocks or even into the thighs

Question 48

Spondylolisthesis imaging

Answer 48

○ X-rays (AP and Lateral) will reveal the slip and can establish grading. ○ CT may be useful in evaluating for fractures if suspected. ○ MRI to evaluate nerves and discs

Question 49

Spinal Stenosis

Answer 49

● Spinal stenosis is a congenital or (more commonly) acquired narrowing of the spinal canal. ● Most common occurs in Cervical or Lumbar areas

Question 50

Clinical Presentation of Cervical Stenosis

Answer 50

○ Cervical stenosis causes the syndrome of Cervical Myelopathy. ○ Usually there is little to no accompanying neck or arm pain. ○ Initial symptoms may be subtle loss of dexterity and strength in the hands, as well as subtle lower extremity weakness.

Question 51

As _____ progresses, the patient will develop Spastic Quadriparesis.

Answer 51

Cervical Stenosis

Question 52

Cervical Stenosis testing

Answer 52

○ Will eventually develop positive Babinski's, hyperreflexia, ankle clonus, and possibly Hoffmann’s sign and Lhermitte’s sign

Question 53

______classically presents with Neurogenic Claudication

Answer 53

lumbar stenosis

Question 54

Spinal Stenosis surgery

Answer 54

○ Surgery generally involves Laminectomy with or without spinal fusio

Question 55

Torticollis

Answer 55

● The term torticollis describes a tilting head position to one side. ○ Lateral bending, often with rotation

Question 56

Also known as “Wry Neck.”

Answer 56

Torticollis

Question 57

Acquired torticollis can develop in infancy or later in life, and can occur secondary to.

Answer 57

■ Blunt force trauma to SCM muscle ■ Sleeping in an unusual position ■ Atlantoaxial rotatory displacement (AARD) ■ Superior Oblique Palsy ■ Idiopathic (Cervical Dystonia)

Question 58

There are two main types of torticollis

Answer 58

○ Congenital Muscular Torticollis (CMT) ○ Acquired Torticollis

Question 59

Torticollis: management of CMT cases

Answer 59

○ CMT cases should be seen early by Orthopedics. ■ Frequent stretching exercises directed at the affected SCM (consider PT). ■ Non-surgical treatment is successful in more than 90% of patients. ■ Significant SCM contraction that does not respond to conservative treatments may undergo release or lengthening of the SCM surgically

Question 60

Torticollis: management of acquired cases

Answer 60

could be referred as well, especially if neurologic symptoms. ■ Treatment depends on the underlying condition causing the Torticollis. ■ Cervical traction and a head halter (with analgesics and muscle relaxants) should be tried (most cases resolve with this treatment). ■ If conservative treatment fails, Halo Traction may be helpful. ■ Surgical intervention is sometimes required, including cervical fusion

Question 62

Kyphosis (hyperkyphosis)

Answer 62

● The thoracic spine normally has kyphosis. ○ T2(3) to T12 Cobb angle of 20-40(50) degrees ● When we refer to kyphosis as a pathologic condition, we are referring to hyperkyphosis. ○ Cobb angle of 50 degrees or more

Question 63

Kyphosis (hyperkyphosis) presentation

Answer 63

○ Most patients come in with a concern for how they look and NOT pain. ○ Pediatric patients may experience mid to low thoracic region backaches with activity that are relieved by rest. ○ Elderly patients commonly have chronic back pain (especially if fractures). ○ Extremely severe kyphosis can cause breathing difficulty (restrictive pattern)

Question 64

Kyphosis (hyperkyphosis) evaluation

Answer 64

○ The Adam Forward bending test will highlight the hyperkyphosis (viewed from lateral angle). ■ Postural kyphosis has a more gentle curvature, where patients with Scheuermann’s disease will have a sharp angulation at the apex

Question 65

Lordosis (hyperlordosis)

Answer 65

● A normal lumbar spine has lordotic curvature. ○ Exaggeration of this curve is called Hyperlordosis (usually lumbar) ○ Hyperlordosis is considered a spinal deformity ● As a pathologic situation, this is very uncommon and usually associated with one of the following disorders

Question 66

Scoliosis

Answer 66

● Scoliosis is defined as a lateral curvature of the spine of > 10 degrees. ○ Determined by the Cobb Method ○ A small amount (<10°) of lateral curvature is considered normal

Question 67

Scoliosis that develops in adulthood is generally secondary to _____

Answer 67

degenerative spondylosis and/or spondylolisthesis

Question 68

Causes (types) of scoliosis

Answer 68

○ Idiopathic (most common) - genetic or environmental factors ○ Degenerative - deterioration of bone, ligament, muscle (elderly) ○ Congenital failure of formation of the vertebrae ○ Neuromuscular - Cerebral Palsy, Muscular Dystrophy ○ Vertebral disease - Tumor, infection ○ Spinal cord disease - Tumor ○ Disease-associated - Marfan’s syndrome

Question 69

Thoracic curves greater than _____ can cause ___

Answer 69

80° to 90° can impair pulmonary function (seen as a restrictive pattern)

Question 70

Scoliosis evaluation

Answer 70

○ The patient’s spine should be inspected in an upright position. ○ The Adam Forward Bend test is the most sensitive clinical method of screening for scoliosis ○ The deformity can be quantified in degrees using an inclinometer such as a scoliometer

Question 71

The _____ is the standard method of quantifying the degree of curvature

Answer 71

Cobb Angle