Spinal Disorders Flashcards
1
Q
Cervical spine x-ray indications
A
trauma infection atypical pain extremity pain osteoporosis degenerative changes
2
Q
Cervical spine x-ray views
A
AP, Later
Odontoid
Swimmer’s
Oblique
3
Q
Cervical spine fractures
A
Jefferson- C1, axial compression, no spinal damage
C2 (axis)- dens, forceful flexion or extension
Hangman’s- C2 fracture involving bilateral pedicles, caused by hyperextension w/ compression, can transect spinal cord
Burst- lower cervical vertebrae, caused by direct axial load, fragments can displace and enter spinal canal
4
Q
Lumbar spine x-ray indication
A
fall from heigh >3 meters fall from standing >60 yo ejection from MVA, pedestrian vs. vehicle Significant trauma Acute, severe back pain neuro deficit/GCS less than 8 Postop imaging chronic conditions hx of cancer w/ back pain
5
Q
Lumbar x-ray views
A
AP/lateral
Oblique
Flexion-extension view (spinal stability, r/o spondylolisthesis)
6
Q
Purpose of oblique view
A
view articular facets and pars interarticularis
7
Q
Radiculopathy
A
cervical/thoracic or lumbar nerve root dysfuntion: all in dermatomal pattern
8
Q
Sciatica
A
lumbar nerve root (L4, L5, S`); along posterior or lateral aspect of lower leg to foot or ankle
9
Q
Radiculopathy s/sx (lower motor neuron/nerve root)
A
weakness/dec. muscle tone
atrophy
hyporeflexia/areflexia
muscle fasciculation
10
Q
Myelopathy
A
injury to spinal cord
11
Q
Causes of myelopathy
A
spinal stenosis trauma infection oncological neurological
12
Q
Myelopathy s/sx
A
increased muscle tone (spasticity) weakness hyperreflexia clonus (sustained) up-going plantar reflex (babinski) Cervical: shooting pain down spine with cervical spine flexion
13
Q
Degenerative diseases in the spine
A
spondylosis
spondylolistehsis
spondylolysis
14
Q
Spondylosis
A
nonspecific, degenerative changes of the spine
15
Q
Spondylolithesis
A
Anterior displacement of a vertebral body due to bilateral defects of the posterior arch
16
Q
Spondylolysis
A
unilateral or bilateral defect (fracture or separation) in the vertebral pars interarticularis, usually in the lower lumbar vertebrae
17
Q
Spinal stenosis causes
A
neurogenic claudication (vascular cause must be rules out),
18
Q
Cause of spinal stenosis
A
acquire vs congenital:
narrowing of central canal, lateral recess or neural formamen
19
Q
Acquired spinal stenosis
A
spondylosis (most common) spondylolisthesis (L4/L5, or L5/S1) Herniated nucleu pulposis (HNP) Ligamentum flavum hypertrophy trauma/post-op (fibrosis) Skeletal disease (RA, ankylosing spondylitis)
20
Q
Congenital spinal stenosis
A
dwarfism, small spinal canal, spina bifida
21
Q
Strain
A
injury to: muscle, tendon, musculotenindous junction
22
Q
Sprain
A
injury to: ligament (bone to bone)
23
Q
Sx of spinal stenosis
A
all areas below stenosis (extremitis/trunk)
pain/numbness/tingling/weakness/bowel/bladder changes
24
Q
Whip lash
A
cervical strain/sprain; due to rapid acceleration-decelration causing rapid neck extension-flexion (rear ended in MVA)
25
What must you do before PE in cervical strain/sprain
thorough hx and clear C-spine (nexus/canadian)
26
Nexus criteria and canadian c-spine rule are used to determine
if imagine is needed prior to testing ROM or manipulation
27
Nexus criteria
1. Absence of posterior midline tenderness
2. Normal alertness
3. no intoxication
4. no abnormal neuro findings
5. no other painful distracting injuries
*if all 5 criteria are met, no imaging needed
28
Canadian C-spine rule
Condition one: radiographs for:
- >65 YO
- dangerous MOI
- paresthesia in extremities
Condition two:
- simple rear end MVA
- sitting position in ED
- ambulatory at any time
- delayed onset of neck pain/or no midline pain
*can test ROM, if rotation to 45 degrees no imaging needed
29
Sx of Cervical strain/sprain
non-radicular, non-focal neck pain from base of skull to cervicothoracic junction
SCM or trap pain
pain worse with motion
spasms of paraspinous muscles
30
PE for cervical strain/sprain
TTP of paraspinous/trap muscles and maybe SCM
limited ROM
neuro exam is usually normal
31
Dx for cervical strain/sprain
AP, later, odontoid; flexion-extension views once C-spin is cleared
all cervical vert must be seen
swimmer's view to visualize cervicothoracic junction
32
Tx for cervical strain-sprain
```
opiods 1-2 weeks
NSAIDs
collar
cervical pillows for sleep
avoid manipulation following trauma until improvement
```
33
Cause of cervical radiculopathy in younger people
HNP (causes neuroforaminal narrowing)
34
Cause of cervical radiculopathy in older patients
decreased intervertebral disc space due to degenerative disease; also could be HNP
35
Signs of cervical radiculopathy
```
neck pain, H/A
pain in upper extremeites (numbness, paresthesia)
Unilateral
pain may radiate down paraspina
weakness/reduced grip strength
```
36
PE for cerv. radiculopathy
```
assess motor/sensory function
assess DTR
loss of lordosis
decreased ROM
gait eval for myelopathy
```
37
Cervical myelopathy sx
trunk or leg dysfunction, gait changes, bowel/bladder changes
38
Imaging for cervical radiculopathy
AP, lateral- may show spondylosis or DDD as a cause of symptoms
MRI w/w/o contrast : HNP as sx
Spine surgeon may order CT myelogram
39
Tx for cervical radiculopathy
```
spontaneous resolution 2-8 weeks
NSAIDs
PT
Possible surgical decompression
pain management referral-epidural steroid
```
40
When to refer for cervical radiculopathy
patient not improving with non-surgical tx
atrophy of muscles develops
sx concerning the "BAD"
41
Osteoarthritis of cervical spine
cervical spondylosis
42
Spondylosis effects what joints
facet joints and intervertebral discs (DDD)
43
Spondylosis may cause
stenosis or neural foraminal narrowing resulting in radiculopathy or myelopathy
44
Sx of spondylosis
```
decreased cervical ROM***
chronic neck pain
sx worse when upright
paraspinous spasm
occipital headaches
bilateral radicular sx associated w/ bilateral foraminal stenosis
advanced: myelopathy
```
45
PE for sponylosis
TTP cervical paraspinal
TTP spinous processes
Decreased AROM of cervical spine
pain with "facet loading"- Spurling test (rotation, extension of neck with +/- applied axial reproduces sx)
46
+ Spurling test
spondylosis
47
Imaging for spondylosis
Ap, lateral
MRI (impingement, inflammation)
CT myelogram (surgeon)
48
Tx for spondylosis
```
sx last several months
NSAIDs
PT
Possible decompression
Possible epdiural or medial branch block/radiogrequency ablation for pain
```
49
Thoracic outlet syndrome
compression of upper extremity neuromuscular bundle above the first rib and behind the clavicle
50
Causes of thoracic outlet syndrome
```
repetitive injury or athlete (pitching)
cervical rib anomaly
muscular anomaly
Trauma- hyperextension/flexion neck injury
Fracture (1st rib/clavicle)
```
51
3 types of thoracic outlet syndrome
neurogenic (nTOS)- brachial plexus
Arterial (aTOS) - subclavian artery
Venous (vTOS)- subclavian vein
52
Most common TOC
neurogenic
53
nTOC
reproducible w/ elevation of arm/sustained use
upper extremity pain
dysesthesia
weakness/numbness
progressive weakness of hypothenar muscle
numbness in ulnar or medial nerve distribution
tenderness over scalene
54
vTOS cause
vigorous, repetitive UE activities
55
vTOS sx
```
SWELLING OF EXTREMITY (HALLMARK)
paresthesia secondary to swelling
upper extremity venous thrombosis
cyanosis
pain in extremity
fatigue in forearm within minutes of use
```
56
aTOS
sx. develop spontaneous unrelated to work/trauma- usually associated with cervical rib
thromboembolism
young patients
ichemia: pain/paresthesia/pallor/coolness to arm/hand
57
Imaging for nTOS
electrodiagnostic testing
| brachial plexus block positive
58
Imaging helpful for aTOS
US, chest-xray (no cervical rib = rules ot aTOS)
59
TOS caused by cervical rib
artery
60
U/x Useful for what TOC
aTOS, vTOS
61
Tx for nTOS
PT for 4-6 weeks
steroid injection, botulinum toxin
decompression surgery for worsening, failed tx
62
vTOS
catheter directed thrombolysis (w/i 2 weeks of onset)
| decompressive surgery
63
aTOS
surgical embolectomy
| decompressive surgery
64
Most rare spine injury
thoracic
65
Most common cause of LBP
lumbar sprain/strain
66
Cause of lumbar sprain/strain
injury to paravertebral spinal muscles; hx of repeated lifting and twisting; acute onset of LBP following lifting episode or bending to pick something up
67
Sx of lumbar sprain/strain
axial pain, radiates to buttocks, may report lumbar spasm, patient may not be able to stand erect and may change position frequently
68
PE of lumbar sprain/strain
TTP to lumbar or SI joint
flexion ROM limited to pain
+/- spasms
normal neuro/DTR
69
Imaging for lumbar sprain/strain
no radiographs unless dangerous MOI;
atypical sx (nigh pain or pain at rest): get AP and lateral radiographs to T10 level (infection, neoplasm, fracture, sponylolisthesis)
70
Tx of lumbar sprain/strain
```
neuro findings: rever
Avoid strenuous activity
NSAIDs/muscle relaxers NOT recommended
PT, TENs unit, U/S
Core strengthening
ROM is good way to assess progress
```
71
Waddell's signs
Non-organic behavior or inappropriate findings:
non-atomic tenderness
simulation sign with minimal compression or rotation
distractions sign
Regional sensor/motor disturbance that doesn't follow dermatome (glove or stocking paresthesia)
overreaction usually to light touch
72
Lumbar spondylosis
pain lasting >3 months (RULE OUT BAD)
| Exacerbated by: injury, repetitive trauma, deconditoning
73
Sx of lumbar spondylosis
LBP that radiates to one or both buttocks****
mechanical pain aggravated by bending or lifting objects from ground
pain relieve with lying down
axial pain usually
normal motor/sensory/DTR
ROM decreased
74
Imaging for lumbar spondylosis
AP/Lateral show: osteophyte formation, disk space narrowing
75
Tx for lumbar spondylosis
PT (core strengthening)
| facet arthritis is present - refer to interventional pain managment for block
76
Lumbar spondylolisthesis sx
may be asymptomatic or minimally symptomatic
back pain that radiates posteriorly to below the knees that is worse with standing
spasms in hamstrings that make it hard to bend forward
limitied flexion
Nerve compression sx rare
77
PE for spondylolisthesis
```
diminished lordosis
step off deformity palpable if severe
more distal = more prominent
decreased ROM flexion
Decreased straight leg raise ROM
```
78
Most common neurogenic leg pain in elderly
Spinal stenosis
79
Imagine for spondylolisthesis
AP radiograph- forward translation of vertebrae
interval radiographs q 6 mo
oblique view for isolated spondylolysis
80
Tx for spondylolisthesis
Refer to ortho spine or neurosurgeon
| may require surgery
81
Lumbar spondylolysis
defect in par interarticularis; usually at L5
Usually seen in adolescents with repetitive forced back extension (football/gymnasts)
usually asymptomatic, incidental finding, may have low back pain
82
Tx for spondylolysis
bracing/PT/Restriction of activity
83
Spondylolysis causes
spondylolisthesis
84
Lumbar HNP cause
lifting/twisting activities increase pressure on the disc causing it to herniate; can also be trauma related; herniation applies pressure to existing spinal nerve roots
85
Lumbar HNP can cause
nerve root compression/radiculopathy
86
Most common locations for lumbar HNP
L4-L5 or L5-S1
87
Sx of lumbar HNP
abrupt onset
unilateral radicular leg pain following LBP
pain is severe and aggravated by sitting, walking, standing, coughing, sneezing
pain radiates down buttocks to posterior or posterior-lateral leg all way down to foot
lying on back with knees elevated or fetal position relieves pain
88
When does HNP cause anterior thigh pain
L1-L4
89
PE for lumbar HNP
(+) straight leg raise
reverse straight leg raise for lesions above L4
LBP and spasms
do complete neuro exam: should follow nerve root distribution
90
Reverse straight leg raise
patient prone, lift hip into extension; pain over antior thigh suggests upper lumbar disk problem above L4
91
Imaging for lumbar HNP
MRI to confirm if:
sx >4 weeks
significant neuro deficit
for pre-op eval
92
Most common cause of neurogenic leg pain in elderly
lumbar spinal stenosis
93
Lumbar spinal stenosis
neurogenic claudication- progressive bilateral leg pain (butt, legs, thighs) that is aggravated by standing/walking; relieved by leaning forward or laying supine; radicular sx can be present without actual back pain
94
Old ladies who hung over shopping cart
Lumbar spinal stenosis
95
Most common cause of lumbar spinal stenosis
spondylosis
96
Sx of lumbar spinal stenosis
may have diminished DTR
wide based gait
possible multilevel sensory defects
SLR + in around 10% patients
97
Imaging for lumbar spinal stenosis
AP, lateral to T10
MRI
CT myelogram but its invasive
EMG/NCS if unclear etiology or to r/o alternate dx
98
Tx for lumbar spinal stenosis
Initial: NSAIDs and PT/opiods; water exercise, epidural steroi injection
Surgical decompression:
No spondylolisthesis: laminectomy or intraspinous spacer implant, MILD if due to ligamentum flavum hyperfrophy
+Spondylolisthesis: lumbar fusion
99
Surgical emergency
cauda equina syndrome
100
Cauda equina syndrome nerves effected
lumbar, sacral and coccygeal nerve roots
101
Causes of cauda equina
```
intervertebral disc herniation
epidural abscess
tumor
lumbar spinal stenosis
metastatic disease (meninges)
infectious
autoimmune
```
102
Sx of cauda equina
leg weakness in multiple distributions (L3-S1) - weak plantar flexion, loss of ankle reflex
LBP w/ radiation to one or both legs
PERINEAL SENSORY LOSS***- sadlle anesthesia- buttocks, perineal, posterior/superior thighs
Urinary retention w/ or w/o incontinence
decreased anal sphincter tone
sexual dysfunction
103
Tx for cauda equina
Dexamethasone 10 mg IV x 1 IMMEDITELY
Emergent MRI w/ contrast; if not, CT myelogram
scan entire spine if concern of metastatic disease or unsure of etiology ; surgical consult
104
First thing you do for cauda equina
administer dexomethasone and page surgery!
105
Malignancy red flags
```
unexplained weight loss
failure of pain to improve w/ tx
duration of pain >1 mo
pain at night (wakes up)
PMHx of cancer
age >50
new onset of spine pain in patient with known malignancy is metastasis until proven otherwise
```
106
infection red flags
```
fever
pain at rest
immunocompromised
IV drug use
hx of recent infection
```
