Spinal Column Disorders Flashcards
Cervical Strain
● 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
Common etiology of cervical strain
whiplash injury
Cervical Strain pathophysiology
○ 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.
Cervical Strain Clinical Presentation
○ 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
Cervical Strain PE
○ 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
Cervical Strain diagnosis
○ 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
Cervical Strain Managemen
○ 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!
Acute Low Back Pain
● 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
Acute Low Back Pain pathophuysiology
○ 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
Acute Low Back Pain presentation
○ 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.
Acute Low Back Pain diagnosis
○ 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.
Acute Low Back Pain management
○ 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
Chronic Low Back Pain
● 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
Once Chronic LBP has been identified, a thorough evaluation should occur, ruling out the following:
○ Cancer (metastatic or primary)
○ Osteoporosis with fractures
○ Osteomyelitis and discitis (infection)
○ Abdominal pathology (aneurysm, retroperitoneal tumor)
Chronic Low Back Pain pathophysiology
○ The most common cause of Chronic LBP is
degenerative disc disease.
○ Other causes include:
■ Lumbar stenosis
■ Ankylosing Spondylitis
■ Old vertebral fractures
Chronic Low Back Pain clinical presentation
○ 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
Chronic Low Back Pain evaluation
○ 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.
X-ray findings of chronic low back pain
■ Osteophytes with decreased disc height
■ May see spondylosis/spondylolisthesis
Narcotic abuse or misuse is a large concern in this group
Chronic Low Back Pain
Spinal Fractures pathophysiology
○ 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.
Spinal Fractures clinical presentation
○ 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)
Spinal Fractures evaluation
○ 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)
Radiologic Imaging of Spinal Fractures
■ 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
Spinal Fractures management
○ 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
The three main goals of spinal fracture treatment are:
■ Prevent Neurologic Injury
■ Restore Stability
■ Restore Normal Function
Sciatica
● 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
Common causes of Sciatic compression
■ Herniated Nucleus Pulposus (disc)
■ Lumbar Spinal Stenosis
■ Traumatic Pelvic Fracture
■ Piriformis Syndrome
In severe cases of _____, foot drop may be
present
sciatica
Most cases of unexplained Sciatica resolve with ______
Physical Therapy, rest, and time.
Herniated Nucleus Pulposus
● 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.
Herniated Nucleus Pulposus pathophysiology
○ 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.
C4-5 herniation may result in a ____
C5 radiculopathy
■ Pain and paresthesias in proximal arm, base of neck, possible deltoid weakness,
possible loss of bicep deep tendon reflex
C5-6 herniation may result in a _____
C6 radiculopathy.
■ Pain and paresthesias in shoulder, radial arm and forearm, thumb and index finger,
possible bicep weakness and bicep DTR loss
C6-7 herniation may result in 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
L3-4 herniation
L4 radiculopathy.
■ Pain over lateral and anterior thigh, down shin, possibly causing loss of patellar
reflex, may involve medial large toe
L4-5 herniation
L5 radiculopathy.
■ Pain over lateral thigh, lateral calf, and may cause a foot drop and paralyzed large toe (no associated reflex)
L5-S1 herniation
S1 radiculopathy.
■ Pain down posterior thigh and into calf, even bottom of
foot and small toe, loss of Achilles reflex and strength
Herniated Nucleus Pulposus testing/evaulation
○ 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.
Herniated Nucleus Pulposus imaging of choice
MRI
Cauda Equina Syndrome
● 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
Clinical Presentation of Cauda Equina Syndrome
○ 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
Digital rectal exam will reveal decreased anal sphincter tone with _____
Cauda Equina Syndrome
Spondylosis
○ 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
Spondylolysis
○ A stress fracture through the pars interarticularis of a lumbar vertebrae.
○ Fairly common and generally secondary to repetitive stress to bone
Spondylolisthesis
○ 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.
X-rays will reveal the so-called “Scotty Dog” sign on oblique films with _____
Spondylolysis
Spondylolisthesis presentation
○ 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
Spondylolisthesis imaging
○ 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
Spinal Stenosis
● Spinal stenosis is a congenital or (more commonly)
acquired narrowing of the spinal canal.
● Most common occurs in Cervical or Lumbar areas
Clinical Presentation of Cervical Stenosis
○ 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.
As _____ progresses, the patient will develop Spastic Quadriparesis.
Cervical Stenosis
Cervical Stenosis testing
○ Will eventually develop positive Babinski’s,
hyperreflexia, ankle clonus, and possibly
Hoffmann’s sign and Lhermitte’s sign
______classically presents with Neurogenic Claudication
lumbar stenosis
Spinal Stenosis surgery
○ Surgery generally involves
Laminectomy with or without
spinal fusio
Torticollis
● The term torticollis describes a tilting head
position to one side.
○ Lateral bending, often with rotation
Also known as “Wry Neck.”
Torticollis
Acquired torticollis can develop in infancy or later in life, and can occur secondary to.
■ Blunt force trauma to SCM muscle
■ Sleeping in an unusual position
■ Atlantoaxial rotatory displacement (AARD)
■ Superior Oblique Palsy
■ Idiopathic (Cervical Dystonia)
There are two main types of torticollis
○ Congenital Muscular Torticollis (CMT)
○ Acquired Torticollis
Torticollis: management of CMT cases
○ 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
Torticollis: management of acquired cases
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
Kyphosis (hyperkyphosis)
● 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
Kyphosis (hyperkyphosis) presentation
○ 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)
Kyphosis (hyperkyphosis) evaluation
○ 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
Lordosis (hyperlordosis)
● 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
Scoliosis
● 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
Scoliosis that develops in adulthood is
generally secondary to _____
degenerative
spondylosis and/or spondylolisthesis
Causes (types) of scoliosis
○ 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
Thoracic curves greater than _____ can cause ___
80° to 90° can impair pulmonary
function (seen as a restrictive pattern)
Scoliosis evaluation
○ 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
The _____ is the standard method of quantifying the degree of curvature
Cobb Angle