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MSK Exam 3 > Spinal Column Disorders > Flashcards

Spinal Column Disorders Flashcards

1
Q

Cervical Strain

A

● 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

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2
Q

Common etiology of cervical strain

A

whiplash injury

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3
Q

Cervical Strain pathophysiology

A

○ 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.

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4
Q

Cervical Strain Clinical Presentation

A

○ 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

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5
Q

Cervical Strain PE

A

○ 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

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6
Q

Cervical Strain diagnosis

A

○ 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

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7
Q

Cervical Strain Managemen

A

○ 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!

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8
Q

Acute Low Back Pain

A

● 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

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9
Q

Acute Low Back Pain pathophuysiology

A

○ 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

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10
Q

Acute Low Back Pain presentation

A

○ 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.

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11
Q

Acute Low Back Pain diagnosis

A

○ 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.

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12
Q

Acute Low Back Pain management

A

○ 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

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13
Q

Chronic Low Back Pain

A

● 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

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14
Q

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

A

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

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15
Q

Chronic Low Back Pain pathophysiology

A

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

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16
Q

Chronic Low Back Pain clinical presentation

A

○ 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

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17
Q

Chronic Low Back Pain evaluation

A

○ 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.

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18
Q

X-ray findings of chronic low back pain

A

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

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19
Q

Narcotic abuse or misuse is a large concern in this group

A

Chronic Low Back Pain

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20
Q

Spinal Fractures pathophysiology

A

○ 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.

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21
Q

Spinal Fractures clinical presentation

A

○ 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)

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22
Q

Spinal Fractures evaluation

A

○ 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)

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23
Q

Radiologic Imaging of Spinal Fractures

A

■ 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

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24
Q

Spinal Fractures management

A

○ 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

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25
Q

The three main goals of spinal fracture treatment are:

A

■ Prevent Neurologic Injury
■ Restore Stability
■ Restore Normal Function

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26
Q

Sciatica

A

● 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

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27
Q

Common causes of Sciatic compression

A

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

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28
Q

In severe cases of _____, foot drop may be
present

A

sciatica

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29
Q

Most cases of unexplained Sciatica resolve with ______

A

Physical Therapy, rest, and time.

30
Q

Herniated Nucleus Pulposus

A

● 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.

31
Q

Herniated Nucleus Pulposus pathophysiology

A

○ 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.

32
Q

C4-5 herniation may result in a ____

A

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

33
Q

C5-6 herniation may result in a _____

A

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

34
Q

C6-7 herniation may result in a _____

A

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

35
Q

L3-4 herniation

A

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

36
Q

L4-5 herniation

A

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

37
Q

L5-S1 herniation

A

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

38
Q

Herniated Nucleus Pulposus testing/evaulation

A

○ 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.

39
Q

Herniated Nucleus Pulposus imaging of choice

A

MRI

40
Q

Cauda Equina Syndrome

A

● 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

41
Q

Clinical Presentation of Cauda Equina Syndrome

A

○ 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

42
Q

Digital rectal exam will reveal decreased anal sphincter tone with _____

A

Cauda Equina Syndrome

43
Q

Spondylosis

A

○ 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

44
Q

Spondylolysis

A

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

45
Q

Spondylolisthesis

A

○ 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.

46
Q

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

A

Spondylolysis

47
Q

Spondylolisthesis presentation

A

○ 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

48
Q

Spondylolisthesis imaging

A

○ 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

49
Q

Spinal Stenosis

A

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

50
Q

Clinical Presentation of Cervical Stenosis

A

○ 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.

51
Q

As _____ progresses, the patient will develop Spastic Quadriparesis.

A

Cervical Stenosis

52
Q

Cervical Stenosis testing

A

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

53
Q

______classically presents with Neurogenic Claudication

A

lumbar stenosis

54
Q

Spinal Stenosis surgery

A

○ Surgery generally involves
Laminectomy with or without
spinal fusio

55
Q

Torticollis

A

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

56
Q

Also known as “Wry Neck.”

A

Torticollis

57
Q

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

A

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

58
Q

There are two main types of torticollis

A

○ Congenital Muscular Torticollis (CMT)
○ Acquired Torticollis

59
Q

Torticollis: management of CMT cases

A

○ 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

60
Q

Torticollis: management of acquired cases

A

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

61
Q
A
62
Q

Kyphosis (hyperkyphosis)

A

● 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

63
Q

Kyphosis (hyperkyphosis) presentation

A

○ 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)

64
Q

Kyphosis (hyperkyphosis) evaluation

A

○ 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

65
Q

Lordosis (hyperlordosis)

A

● 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

66
Q

Scoliosis

A

● 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

67
Q

Scoliosis that develops in adulthood is
generally secondary to _____

A

degenerative
spondylosis and/or spondylolisthesis

68
Q

Causes (types) of scoliosis

A

○ 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

69
Q

Thoracic curves greater than _____ can cause ___

A

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

70
Q

Scoliosis evaluation

A

○ 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

71
Q

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

A

Cobb Angle

MSK Exam 3 (6 decks)

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