Spinal Disorders Flashcards
What would you see on X-ray of lumbar spondylosis?
Osteophyte formation
Disc space narrowing
What do the nexus criteria and Canadian c-spine rules do?
tools that tell us when we don’t need imaging of a c-spine injury
How would you diagnose arterial or venous thoracic outlet syndrome?
Ultrasound ***
Chest X-ray to check for cervical rib
(If no cervical rib you can almost definitely rule out aTOS)
Can cervical spondylosis progress to radiculopathy or myelopathy
Yes, it can cause stenosis
What is spondylolysis
Fracture or separation in the pars interarticularis, usually in the lower lumbar vertebrae
Will lumbar strain/sprain cause an abnormal neuro/motor/DTR exam in legs?
No
What is a burst fracture?
Fracture of lower cervical vertebrae caused by direct axial load
Fragments all over the place
What is Spondylosis
Nonspecific, degenerative changes of the spine
What test can be done to check for cervical spondylosis?
Spurling test- put pressure on facet joints and turn head= pain
***
What is spondylolisthesis?
Anterior displacement of a vertebral body due to bilateral defects of the posterior arch
Saddle anesthesia
Cauda equina syndrome
Where is the most common place to see spondylolisthesis?
Lumbar
What will you see on X-ray of lumbar spondylolisthesis
Forward translation of vertebrae
Who usually gets lumbar spondylolysis?
Adolescents with repetitive forced back extension***
Football players, gymnasts
What are the clinical signs of cervical radiculopathy?
Neck pain/occipital headaches
Numbness/tingling in upper extremities that follow a dermatomal pattern
Unilateral
Pain may radiate down paraspinal muscles
Weakness and reduced grip strength
What is the most common way to get spinal stenosis?
Spondylosis (arthritis in spine)
In a cervical strain/sprain, is pain worse with motion?
Yes
What is the first X-ray view you do for the spine
AP
Also do lateral
Is there always back pain with lumbar spinal stenosis?
No it may just be leg pain
What is the treatment for lumbar spondylosis?
PT: core strengthening
If facet arthritis is present, refer for MBB and RFA
Should we do imaging for lumbar sprain/strain
No, not unless there was a dangerous MOI or you suspect cancer
What are the nexus criteria?
Absence of posterior midline tenderness
Alert and sober
No abnormal neurologic findings
No distracting injuries
*if all of these are present, don’t do c-spine imaging. BUT if one of these conditions is not met, you must do imaging
What are the cause of thoracic outlet syndrome?
Repetitive injury (ex. Pitchers)
Cervical rib anomaly (extra rib)
Muscular insertions are weird
Injury (fracturing rib/clavicle, or whiplash)
What what is the most common cause of neurogenic leg pain in the elderly
Lumbar spinal stenosis
What are the symptoms of venous thoracic outlet syndrome
Typically related to vigorous repetitive UE activities
Swelling of arm *** Classic
Cyanosis
Pain in extremity
Fatigue in forearm within minutes of use
Can pateients have radiculopathy and myelopathy at the same time?
Yes
What is the treatment for vTOS?
Thrombolysis
Decompressive surgery
Is cauda equina syndrome an emergency?
Yes
What is the difference between strain and sprain
Strain- injury to muscle, tendon,
Sprain- injury to ligaments
What is the treatment for nTOS?
PT for 4-6 wks
Steroids
Botox
Decompression surgery if needed
(This is not limb threatening so we try conservative tx first)
What causes neurogenic claudicatoin
Spinal stenosis
What is a CT Myelogram and who is it good for?
It’s a real time CT with contrast thats best for evaluation of spinal cord, nerveroots, meninges, disc abnormalities and its good for patients who cant undergo MRI due to metal or whatever
What is the diagnosis in >80% of people with lower back pain?
Lumbar strain/sprain
What is a Jefferson fracture
Fracture of C1 caused by axial compression (diving)
No spinal cord damage
How long must the LBP last to diagnose lumbar spondylosis?
Longer than 3 months
Is thoracic spine pain common?
No
What is the difference between the presentation of lumbar spondylolysis in a teen vs an older person?
In a teen, it’s going to be an isolated fracture
In an old person, its going to be accompanied by spondylolisthesis (the slippage usually causes the pars fracture)
What is a hangman’s fracture?
C2 fracture involveing Bilateral pedicles.
Caused by hyper extension with compression (high speed MVA)
May transects spinal cord
What nerve root causes pain in neck, shoulder, medial forearm, 4th and 5th fingers, medial hand
Numbness in medial forearm, medial hand, 4th and 5th digits
C8
If they have lower back pain and a history of repeated lifting and twisting, or an acute onset of LBP following a trivial lifting or bending episode, what should you think?
Lumbar strain/sprain
What is the treatment for aTOS?
Surgical embolectomy
Decompressive surgery
What is the treatment for a cervical strain/sprain?
most people have spontanesou resolution in 4-6 wks although whiplash injuries may take longer
Short term opioids
NSAIDs
C-collar short term (don’t want atrophy)
Cervical pillows while sleeping
What are the red flags for infection
Fever
Pain at rest
Immunocompromised patient
IV drug use
Hx of recent infection, espeically: UTI, cellulitis, or pneumonia****
What are the symptoms of arterial thoracic outlet syndrome
Symptoms develop spontaneously unrelated to work/trauma
Almost ALWAYS associated with a cervical rib
Young patients- it’s a congenital anomaly
Thromboembolism in hand/arm
Arm/hand ischemia- pain, paresthesia, pallor, coolness
What can cause cervical Radiculopathy in older patients
Degenerative disease causing narrowed foramen
Herniated disc
What are Waddell’s signs?
Non-organic behavior or inappropriate findings. That are suggestive of drug-seeking:
Non anatomical pain
Simulation sign- using minimal axial compression or rotations cause unusually sever pain
Distractions sign- check straight leg raise when they;’re not paying attention and then again when they are and compare
Glove/stocking type paresthesia-Sensory/motor disturbance that does not follow a dermatomal pattern
Overreaction to light touch
What is the treatment for cauda equina syndrome
IMMEDIATELY give dexamthasone 10mg IV
Emergent MRI or CT myelogram of the lumbar and sacral spine
Surgical consult for decompression or radiation if metastatic tumor
What is myelopathy?
Damage to the spinal cord (not nerve root) and symptoms will be from lesion down
What does the swimmers view allow us to see?
Cervicothoracic junction
Will motor, sensory, and DTR dysfunction follow a nerve root pattern in lumbar HNP?
Yes
What are the clinical signs of lumbar spondylolisthesis
Might be minimally symptomatic
Pain that radiated posteriorly to knees that is worse with standing
Hamstring spasms that make it hard to bend forward
Nerve compression symptoms are rare
What is the most common site of a lumbar herniated disc
L4-L5
L5-S1
What kind of imaging should be ordered for a herniated disc?
MRI if:
It’s super bad
Lasts 4 weeks+
Before surgery
(Xrays are unhelpful)
What are the additional X-ray views you need to order of the C-spine when there’s trauma
Odontoid peg (C1 and C2)
Swimmers view (C7-T1)
Oblique R/L (facet joints)
What causes cervical spondylosis?
Osteoarthritis of the cervical spine (facet joints are arthritic, or IV discs flatten due to DDD)
Osteophyte formation
Thickening of ligamentem flavum
What is the treatment for lumbar spinal stenosis?
NSAIDs
PT
Opioids
Water exercise
ESI
Surgery (if they do not have spondylolisthesis, we can do a laminectomy or a spacer implant, or we can do a MILD if due to ligamentum flavum hypertrophy. If they DO have spondylolisthesis, we can do lumbar fusion )
What are the clinical signs of a lumbar HNP?
Abrupt pain
Unilateral radical leg pain
Pain aggravated by sitting, walking, standing, coughing and sneezing
Pain radiated down buttocks to posterior/lateral leg down to foot
Lying on back with knees elevated or in fetal position relieves the pain**
Injury higher than L4 will cause anterior thigh pain (but that’s unusual)
How would you diagnose neurogenic thoracic outlet syndrome?
Electrodiagnostic testing (EMG, NCS)
Brachial plexus block (like an MBB)
What specialized exam will be positive in lumbar HNP?
Straight leg raise **classic
Reverse straight leg raise for higher injury
When do we do cervical spine x-rays?
If traumatic injury or older patient
What is the treatment for lumbar strain/sprain?
Avoid strenuous activity
NO BEDREST
NSAIDs
NO muscle relaxers
PT, TENs unit
Core strengthening
What is a “Scotty Dog Fracture”
Lumbar spondylolysis
What is the treatment for cervical myelopathy?
Spontaneously resolves in 2-8 wks
NSAIDs
PT with cervical traction** disc might pop back in
Possible surgical decompression
Pain management referral
ESI** calming inflammation may pop disc back in
What is the treatment for cervical spondylosis
Symptoms may last several months
NSAIDs
PT
Possible surgical decompression
ESI
MBB+RFA
What would you find on physical exam of lumbar spondylolisthesis
Diminished lumbar curve
Step off deformity if severe
Decreased forward flexion
Decreased ROM of straight leg raise. No pain it just wont go
What are the symptoms of cervical myelopathy?
Trunk or leg dysfunction
Gait changes
Bowel/bladder changes
(Remember myelopathy is from the lesion down)
What are the most common levels to have spondylolisthesis, causing spinal stenosis?
L4-L5
L5-S1
Should we give muscle relaxers and tell our pt to go on bed rest if they have a lumbar strain/sprain
NO
What nerve root causes:
Neck, shoulder, scapula lateral arm, lateral forearm and lateral hand pain
Numbness in lateral forearm, thumb and index finger
C6
What are the Canadian c-spine rules?
Condition 1:
X-ray any patient with: age 65+, dangerous MOI, paresthesia in extremities
Condition 2: if none of those factors are met, you need to see if it’s safe to check their ROM. (Simple rear end MVA, sitting up, walking, delayed neck pain)
If they can not move their neck 45 degrees in both directions, then you need to X-ray.
If they can, then no x-rays are needed.
Do you do flexion/extension X-ray views of the c spine right away?
No, must clear c spine first
What kind of imaging needs to be done with lumbar spinal stenosis?
X-rays to T10
MRI over CT
CT myelogram is helpful but invasive
EMG/NCS if you cant figure out their leg pain
What makes the neurogenic claudication of lumbar spinal stenosis worse?
Standing
Walking
What are EMG and Nerve conduction studies
EMG-detects response of muscle to nerve stimulation
NCS- determines specific site of lesion
Always ordered together
What are the signs of cauda equina syndrome?
Leg weakness in multiple distributions (L3-S1)
LBP with radiation into legs
SADDLE ANESTHESIA*** S2-S4
Urinary retention with or w/o overflow incontinence
Decreased anal sphincter tone
Sexual dysfunction
What is the treatment for lumbar spondylolisthesis
Surgery
What makes lumbar spondylosis worse and what makes it better?
Worse: bending or lifting
Better: lying down
What nerve root causes pain in neck shoulder middle finger and hand
Numbness in index and middle finger
C7
What makes the neurogenic claudcation feel better?
Leaning forward
SHOPPING CART SIGN**
What is Radiculopathy?
Caused by a “pinched nerve” root and you have symptoms in a dermatomal distribution
What is the most common cause of a cervical strain/sprain?
Whiplash
Wat is the hallmark symptom of lumbar spondylosis?
LBP that radiates to buttocks
What is thoracic outlet syndrome?
Compression of the neurovascular bundle above the first rib and behind the clavicle
(Subclavian artery and brachial plexus)
Will someone with lumbar spinal stenosis have a wide based gait?
Yes
Why would you use an oblique view to look at lumbar spine
To visualize the articular facets and the pars interarticularis
What is the biggest cause of thoracic spine injury
Trauma.
So we wanna look for bruising and step-offs
What is the most common type off thoracic outlet syndrome
Neurogenic is 95%
Compression of brachial plexus
What are some of the ref flags of malignancy?
Unexplained weight loss
Failure of pain to improve
Pain >1 month
Pain at night (wakes from sleep)
History of cancer
50+ years old
New onset of spine pain in pt with known malignancy (50-70% of pts with terminal cancer will have vertebral Mets)
What vertebrae is affected 90% of the time by lumbar spondylolysis
L5
What are the symptoms of neurogenic thoracic outlet syndrome
Reproducible with elevation of arm (ex. While painting**)
Upper extremity pain
Dysesthesia (severe paresthesia/bugs crawl)
Weakness/numbness in hand, arm, shoulder (NOT dermatomal…its not a spinal root being compressed)
Weakness of hypothenar muscles
Numbness in ulnar or median nerve distribution
Tender over scalene muscles
What nerve root causes:
neck shoulder and scapula pain
Lateral arm numbness
C5
What are the three types of thoracic outlet syndrome
Neurogenic- brachial plexus compression 95%
Arterial- subclavian artery compression 1%
Venous- subclavian vein compression 3%
How does C2 get fractured
Forceful flexion or extension of neck (MVA, assault)
What can cause cervical Radiculopathy in young patients
Herniated disc
What is lumbar spondylolysis?
A fracture of the pars interarticularis
“Scotty Dog Fracture”
What is the most common symptom of cervical spondylosis
Decreased ROM of c spine
What is the most common cause of lumbar spinal stenosis?
Spondylosis
What is sciatica?
Radiculopathy in a lumbar nerve root (L4, L5, or S1)
Symptoms along the posterior or lateral aspect of the lower leg to foot or ankle
