Spinal Disorders Flashcards
Specific risk factors for low back pain
Poor abdominal musculature, obesity, pregnancy
What is a CT myelogram?
Real time CT with injection of contrast material
Best to evaluate spinal cord, nerve roots, meninges, disc abnormalities (or post op study or patients who can’t do MRI)
Neurophysiology studies
Measure electrical activity in muscles and nerves
Electromyography: detects response of muscle to nerve stimulation
Nerve conduction studies: can determine specific site of nerve injury
Often ordered together
What do you look for on spine plain films (x-ray)?
Alignment, disk space narrowing, fractures, degenerative changes, presence of osteophytes (especially in intervertebral foramina)
Indications for cervical spine xray
Trauma, infection, atypical pain, extremity pain, osteoporosis, degenerative changes
Cervical spine x-ray views and which ones are needed in trauma
AP, lateral:
Trauma: odontoid (mouth open view), swimmers view (C7-T1), oblique (R/L)
Jefferson fracture
C1 (atlas)
Caused by axial compression with typically no spinal cord damage
C2 (axis) fracture
Odontoid (dens)
Caused by forceful flexion or extension
Hangman’s fracture
C2 fracture involving bilateral pedicles
Caused by hyperextension with compression
Can transect spinal cord
Burst fracture
Lower cervical vertebra
Caused by direct axial load
Fragments displaced in all directions, can enter spinal canal
Indications for lumbar spine xray
Trauma/fall/accident Acute, severe back pain Neurological deficit/GCS less than 8 Post-op Chronic conditions History of cancer and associated back pain
Views of lumbar spine xray
Lumbar (AP/lateral)
Oblique view (see facets and pars interarticularis)
Flexion-extension view
Radiculopathy
Cervical/thoracic or lumbar nerve root dysfunction, ALL in a dermatomal distribution
Sciatica
Radiculopathy in a lumbar nerve root (L4, L5 or S1)
Nerve symptoms along posterior or lateral lower leg to foot or ankle
Signs of radiculopathy
Neurologic deficit related to lower motor neuron or nerve root in a dermatomal pattern (weakness/decreased muscle tone, muscle atrophy, hyporeflexia/areflexia, muscle fasiculation)
Myelopathy
Injury to the spinal cord from spinal stenosis, trauma, infection, cancer or neurological
Signs of myelopathy
Increased muscle tone (spasticity), weakness in affected distribution, hyperreflexia, clonus (sustained), Babinski sign, cervical (shooting pain down spine with cervical spine flexion)
Spondylosis
Nonspecific, degenerative changes of spine
Spondylolisthesis
Anterior displacement of a vertebral body due to bilateral defects of posterior arch
Spondylolysis
Unilateral or bilateral defect (fracture or separation) in vertebral pars interarticularis, usually in lower lumbar vertebrae
Spinal stenosis
Causes neurogenic claudications (vascular cause must be ruled out)
Acquired or congenital (narrowing of central canal, narrowing of lateral recess, narrowing of neural foramen)
Acquired spinal stenosis
Most common is spondylosis
Spondylolisthesis (L4-L5 common with L5-S1 next)
Space occupying lesion/herniate nucleus pulposis, ligamentum flavum hypertrophy
Traumatic/post-op causes (fibrosis)
Skeletal disease
Congenital spinal stenosis
Dwarfism
Congenitally small spinal canal
Spina bifida
Cause of cervical strain/sprain
Frequently due to whiplash mechanism with rapid acceleration-deceleration causing rapid neck extension/flexion
What is needed before exam of C spine?
Clear the C spine with Nexus or canadian criteria for imaging (if don’t meet one or either, must clear with imaging before ROM and manipulation)
Nexus criteria
Absence of posterior midline tenderness Normal level of alertness No evidence of intoxication No abnormal neurologic findings No other painful distracting injuries *If all 5 met, no imaging needed
Canadian C-Spine Rule
Condition one:
Perform radiographs in patients with any of the following (age 65+, dangerous MOI, paresthesia in extremities)
Condition two:
In pts without high risk factors, asses for low risk factors that allow for safe assessment of neck ROM (simple rear end MVA, sitting position in ED, ambulatory at any time, delayed onset neck pain/or no midline pain
*can test ROM, if rotation to 45 degrees than no imaging needed
Signs of C spine strain/sprain
Pain following traumatic incident or can be spontaneous
Non-radicular, non-focal neck pain anywhere from base of skull to cervicothoracic junction
May have SCM or trap pain
Pain worse with motion
May have spasms of paraspinous muscles
Exam of C spine strain/sprain
TTP paraspinous/trap muscles and maybe SCM
Limited ROM rotation, lateral flexion and flexion/extension often at extremes
Neurologic exam is usually normal when isolated
Diagnostic tests for C spine strain/sprain
AP, lateral and odontoid view for traumatic injury or older pts
Flexion extension views when C spine cleared
All cervical vertebrae must be seen
Swimmer’s view to see cervicothoracic junction
Treatment for C spine strain/sprain
Short course of opioids in acute setting but not longer than 1-2 wks
Short use of NSAIDs for pain and inflammation
Soft cervical collar in acute setting
Cervical pillows to sleep
Avoid manip of c spine following traumatic injury until improved
Outcome of c spine strain/sprain
Most spontaneous resolve 4-6 wks
Whiplash might be longer
Patients with pre-existing c spine pathology may have more intractable symptoms
Possible radiculopathy or myelopathy after this
Reasons for cervical radiculopathy
Younger: HNP of cervical disk and can cause neuroforaminal narrowing
Older: foraminal narrowing from decreased intervertebral disc space from degenerative disease, maybe from HNP
Clinical signs of cervical radiculopathy
Neck pain/possible occipital headaches
Radicular sxs in UE that follow a nerve root pattern (numbness/paresthesia)
Typically unilateral (unless cervical spinal stenosis)
Pain may radiate down cervical paraspinal muscles/spasms
Weakness/reduced grip strength
What do you need to remember about cervical radiculopathy and myelopathy?
They are not mutually exclusive!
Sxs of cervical myelopathy
Trunk or leg dysfunction
Gait changes
Bowel or bladder changes
*always do a good neuro exam
Tx for cervical myelopathy
Spontaneous resolution usually 2-8 wks
NSAIDs for pain/inflammation
PT referral with cervical traction
If significant stenosis, radiculopathy, myelopathy then surgical decompression
Pain management referral for epidural steroid injections
When do you refer with cervical myelopathy?
Pt not refer with non-surgical tx
Pts develop atrophy in muscles associated with nerve root
Pts that present with signs concerning for the “BAD”
What is cervical spondylosis?
Osteoarthritis of the cervical spine (can be facet joints or intervertebral discs causing degenerative disc disease DDD)
Osteophyte formation
Thickening of ligamentum flavum
May cause stenosis or neural foraminal narrowing
Clinical signs of cervical spondylosis
Most common sx is decreased c spine ROM
Chronic neck pain
Sxs usually worse with upright activity
May have paraspinous muscle spasm
Occipital headaches
Bilateral radicular sxs associated with bilateral stenosis
Advanced stenosis of cervical spinal canal may show myelopathy
Exam of cervical spondylosis
TTP of cervical paraspinal muscles and spinous processes
Decreased AROM of c spine
Pain with facet loading spurling test
Spurling test
Rotation and extension of the neck +/- applied axial reproduced sxs
Tx for cervial spondylosis
Sxs might last several months NSAIDs for pain and inflammation PT referral Surgical decompression Pain management: epidural steroid injections, diagnostic medial branch block followed by radiofrequency ablation
What is thoracic outlet syndrome?
Compression of the upper extremity neurovascular bundle above the first rib and behind the clavicle
Causes of thoracic outlet syndrome
Repetitive injury or athletic arm movements (pitching)
Cervical rib anomaly (articulates with 1st thoracic rib)
Muscular anomalies
Injury (trauma like hyperextension/flexion of neck or fracture of 1st rib/clavicle)
3 types of thoracic outlet syndome
Neurogenic (brachial plexus compressed 95%)
Arterial (subclavian artery compressed 1%)
Venous (subclavian vein compressed 3%)
Presentation of nTOS
Reproducible with elevation of arm/sustained use
UE pain
Dysesthesia
Weakness or numbess (hand/arm/shoulder)
Progressive, unilateral weakness of hypothenar muscle
Numbness in ulnar or medial nerve distribution
Tenderness over scalenes
Presentation of aTOS
Sxs develop spontaneously unrelated to work/trauma
Almost always due to cervical rib
Young patients (no atherosclerotic risk factors)
Thromboembolism to hand/arm
Arm/hand ischemia: pain, paresthesia, pallor, coolness
Presentation of vTOS
Typically due to vigorous, repetitive UE activities
UE venous thrombosis
Swelling of extremity (HALLMARK)- paresthesia secondary to swelling
Cyanosis
Pain in extremity
Fatigue in forearm within minutes of use
What is electrodiagnostic testing useful for diagnosing?
nTOS
When is a brachial plexus block positive?
nTOS
When do you use US as an initial image to diagnose a TOS?
aTOS or vTOS
When do you use chest xrays to diagnose a TOS?
If no cervical rib, then can almost defintively rule out aTOS
Tx for nTOS
PT for 4-6 wks
Medical therapy: steroid injections, botulinum toxin type A
Decompression surgery for worsening sxs, failure of conservative tx
Tx for vTOS
Catheter directed thrombolysis (best within 2 wks of sx onset)
Decompressive surgery
Tx for aTOS
Surgical embolectomy
Decompressive surgery
Causes of thoracic pain
Trauma, muscle strain, spondylosis, spondylolisthesis (less common), thoracic disc herniation, unilateral or bilateral dermatomal pain (band-like)
Exam for thoracic spine pain
Focal pain or tenderness over thoracic spine
Signs of injury along thoracic spine
Neurologic deficit consistent with thoracic injury
*criteria for imaging same as lumber spine
What is the most common diagnosis of LBP?
Lumbar sprain/strain
Clinical signs of lower back sprain/strain
Pain usually axial in nature, might radiate to buttocks, may have lumbar spasm
Pt may not be able to stand erect or may change position frequently
When do you want to image for low back pain?
When pt has atypical sxs such as night pain of pain at rest
Obtain AP and lateral radiographs to T10 level
Evaluate for infection, neoplasm, fracture, spondylolisthesis
Tx for lumbar sprain/strain
Neurologic findings refer to specialist
Avoid strenuous activity
Begins NSAIDs (muscle relaxors not recommended)
PT, tens, US
Core strengthening when pain resolves
Improvement in ROM is good way to assess progress
What are Waddell’s signs?
Non-organice behavior or inappropriate findings like:
Non-anatomic tenderness
Simulation sign using minimal axial compression or rotation causing unusually severe pai
Distractions sign (straight leg raise when attention and distract)
Glove or stocking type paresthesia (not follow dermatome of myotome pattern)
Overreaction to light touch
How long do you see pain in lumbar spondylosis?
Longer than 3 months
Can be exacerbated by injury, repetitive trauma or deconditioning
Hallmark sx of lumbar spondylosis
LBP that radiates to one or both buttocks
Clinical signs of lumbar spondylosis
Mechanical pain aggravated by bending
Pain usually relieved lying down but trouble staying there
Usually axial pain unless foraminal stenosis secondary to arthritis
Normal motor/sensory/DTRs
ROM may be decreased
What can you see in AP and lateral radiographs of lumbar spondylosis?
Osteophyte formation and disk space narrowing
Tx for lumbar spondylosis
PT: core strengthen
If facet arthritis then refer to interventional pain management for medial branch blocks or ablation
Clinical signs of lumbar spondylolisthesis
May be symptomatic or minimally sxs Back pain that radiates posteriorly to below knees that is worse with standing Pt may report spasms in hamstrings Limited forward flexion Nerve compression sxs rare
Exam of lumbar spondylolisthesis
Diminished lumbar lordosis
If forward slippage is significant then step off deformity may be palpable
More distal vertebrae involved will be more prominent
Decreased forward flexion ROM of lumbar spine
Decreased straight leg raise ROM
Tx for lumbar spondylolisthesis
Refer to ortho spine or neurosurgeon because may need surgical fixation
Most common lumbar spondylolysis seen
Defect in pars interarticularis “scotty dog fracture” which is 90% of time at L5
Adolescents with repetitive forced back extension (football player, gymnast)
Often asymptomatic
Tx for lumbar spondylolysis
Bracing, PT, restrict activity
Cause of lumbar HNP
Lifting and twisting activities increase pressure on disc causing it to herniate
Can be trauma related
Herniated substance applies pressure to exiting spinal nerve roots
Can cause nerve root compression/radiculopathy
Where is lumbar HNP most common?
L4-L5 or L5-S1
Clinical signs of lumbar HNP
Onset of pain is abrupt
Unilateral radicular leg pain follows acute LBP
Pain is severe and aggravated with sitting, walking etc
Pain radiates to buttocks to posterior or posterior lateral leg all the way to foot
Lying on back with knees up or in fetal position relieves pain
If between L1-L4, may see anterior thigh pain
Exam of lumbar HNP
Positive straight leg raise (symptom reproduction)
Reverse straight leg raise for lesion above L4
Typically LBP and spasms
Complete neuro exam with motor, sensory and DTR dysfunction following nerve root distribution
What is the reverse straight leg raise?
For lumbar HNP L1-L4
Patient is prone and we lift hip into extension while keeping knee straight
Pain over anterior thigh suggests upper lumbar disk prob
When is an MRI needed to confirm diagnosis of lumbar HNP?
Sxs over 4 wks
Significant neuroligic deficit identified
For pre-op
*MR on all pts with back pain not recommended because may show bulging of disc without compression
What is the most common cause of neurogenic leg pain in elderly?
Lumbar spinal stenosis
Sxs of lumbar spinal stenosis
Neurogenic claudication (progressive bilateral leg apin that is aggravated with standing or walking)
Relieved by leaning forward or laying supine 15-30 min
Radicular sxs can be present without actual back pain
Most common cause of lumbar spinal stenosis
Spondylosis
Imaging in spinal stenosis
AP and lateral xrays to T10
MRI over CT
CT myelogram has good correlation with MRI but invasive
EMG/NCS is unclear or rule out other diagnoses
Tx for spinal stenosis
Initially may need NSAIDs, opioids or PT
Water exercise for elderly
Epidural steroid injections
Surgery
When do you do surgical decompression in spinal stenosis?
With no spondylolistheis do a laminectomy or intraspinous spacer implant or MILD (minimally invasive lumbar decompression) if due to ligamentum flavum hypertrophy
Lumbar fusion with spondylolisthesis
Cauda equina syndrome is a…..
SURGICAL EMERGENCY
What is cauda equina syndrome?
Compression of lumbar, sacral, coccygeal nerve roots
Diagnosis can be challenging early on
Varied presentation
Causes of cauda equina syndrome
Intervertebral disc herniation Epidural abscess Tumor Lumbar spinal stenosis Metastatic disease (meninges) Infectious Autoimmune
Clinical signs of cauda equina syndrome
Leg weakness in multiple distributions (L3-S1)- weak plantar flex or loss of ankle reflex (S1-S2)
LBP radiating into one or both legs
Perineal sensory loss (S2-24)
What are the signs of perineal sensory loss?
Saddle anesthesia: most common in butt, perineal region, posterior/superior thighs
Urinary retention with or without overflow incontinence
Decreased anal sphincter tone (60-80%)
Sexual dysfunction
Tx for cauda equina syndrome
If suspicious: dexamethasone 10 mg IV x 1 immediately
Emergent MRI with contrast (CT myelogram if can’t do that)
Scan entire spine if concern for metastasis or unknown etiology
Treat depending on etiology of cord compression
Surgical consult for decompression or radiation therapy if metastatic tumor
Malignancy red flags
Unexplained weight loss Failure of pain to improve with tx Duration of pain over 1 month Pain at night PMHx of cancer Age over 50 New onset of spin pain in pt with known malignancy is metastasis until proven otherwise (50-70% pts with terminal cancer have vertebral mets)
Infection red flags
Fever Pain at rest Immunocompromised pt IV drug use Hx of recent infection (UTI, cellulitis, pneumonia)
