Spinal specific pathology

Question 1

Fracture

Answer 1

-Trauma?
Questioning? Throbbing, constant, unremitting
Observation – bruising
Palpation?
Compression?
Percussion?
Tuning fork (lasts 20 secs after taking tuning fork off – lingering Px).
Fracture that hasn’t healed in 6-8 weeks – osteoporosis risk factors?

Increased suspicion if: Older age; prolonged corticosteroid use; severe trauma; presence of abrasion or contusion; night P.

• Immediate spinal P post injury, focal bony tenderness in midline; P with extension
• More significant trauma increases likelihood of #; ACR suggest 5 stairs height or 3 feet
• Steroid use of 7.5mg for 3 months increases risk of OP
• Trauma – Rib fracture or trauma into L side - splenic rupture (Kehrs sign?)
• 20% of women over 70 have spinal # - 70% of these won’t know

Question 2

Osteoporosis

Answer 2

• Early menopause, smoking, hysterectomy, diet, gastrointestinal morbidity, late menarche
• Prev Hx of osteoporotic # have 5.4-fold risk of vert # and 2.8-fold risk of hip #
• Peak bone mass is attained in early 20s – bone mineral density in femoral neck, total hip + LSP reaches peak by 20- 24 in M and 19-20 in F (Xue et al 2020)
• Medication for osteoporosis will decreases risk for # in following year by 50-80%
• +ve family history increases risk especially in F.

1st signs – falls/fragility
DEXA scan: T-score interpretation:
-1 or higher: Normal bone density
-1 to -2.5: Osteopenia
-2.5 or lower: Osteoporosis

Question 3

Malignancy

Answer 3

70% of secondaries go to TSP.
20% LSP
10 CSP

Tumor is suspected if the client has painless neurologic deficit, night pain, or pain that increases when supine. Non-mechanical Px, no position of ease.
- Suspicion – Prev Hx, old age, unexplained weight loss, Prev Hx or FHx cancer
- Smoker – Lung Ca
- Immunosuppression or steroid use

Question 4

Key constitutional signs

Answer 4

1. Unexplained weight loss
2. Fatigue/malaise
3. Fever
4. Night sweats
5. Loss of appetite
6. Generalised Pain/feeling of unwell
7. Frequent infections

Question 5

Metastise

Answer 5

• History of malignancy - Qs: how long ago was primary Dx; stage/size of cancer; lymph involvement; TTT? (chemo, radio, hormonal)
• Lower suspicion (early stae 1 or 2, no lymph involvement, cancers that don’t predilect to bone (ovarian, melanoma)
• Higher suspicion (later stage 3 or 4, lymph involvement, breast, lung, thyroid, renal, prostate.)
  Breast cancer metastases can occur @ any time, 50% occur in 1st 5 years and 50% 10 + years
• Breast 21%
• Lung 19%
• Prostate 7.5%
• Renal 5%
• Thyroid 2-3%

Question 6

AxSPA Most common 3:

Question 7

AxSPA

Answer 7

• Chronic Back pain (3+ months w/back P onset before 45 and Hx of: Inflam Back P; Peripheral manifestations; extra-articular manifestations (iBD , psoriasis, uveitis); +VE FHx and good response to NSAIDS
• Inflam Back P = onset below 40; insidious onset; improve w/ exercise; no improve w/ rest, Night P which decreases upon getting up.
• Refer to rheumatology

Question 8

SCREENDEM

Answer 8

Skin - Psoriasis
Colitis or Chrons
Relatives
Eyes - Uveitis
Early morning stiffness more than 30mins
Nails - pitting, thickening, onycholysis
Dactylitis
Enthesitis - commonly achilles tendon, PF or patella tendon
Movement and medication - improvement with rest and NSAIDs

Question 9

Infecton

Answer 9

Most commonly discuitis
- Triad of: Spinal P, fever and neuro deficits
- Fever/chills only present in 50% of cases
- Fever: Often low-grade and may be intermittent.
- Night Sweats: A common systemic symptom of tuberculosis.
- Weight Loss: Unintentional weight loss and loss of appetite due to chronic illness.
- Fatigue: Feeling weak and tired due to the body’s response to infection.
- Chronic and persistent back P
- Weakness or Paralysis: In severe cases, the infection can compress the spinal cord
- P at rest of night
- Recent injury or spinal or dental surgery
- FM + drug use common in leading to immunocompromised
- Poor living conditions, family Hx of TB
- Recent operation/immunosuppressed

Question 10

CES

Answer 10

• New B and B dysfunction, perianal numbness or Saddle anaesthesia, persistent or progressive LMN changes
• Causes: Congenital, Trauma, Surgery, Spinal stenosis, Infection, Tumour, Disc herniation (CE is a complication of DH in 2% of cases)
• Impact of late diagnosis: 1/5 have poor outcome; ongoing TTT for sexual dysfunction; self-catheterization; colostomy; psychosocial issues; litigation (30-40 cases annually); 1000 ops annually; cost annually = 336,00 – 636,000 in 2018.
• Unilateral back P progressing to Bi leg P is worrying.
• Bi leg P in isolation isn’t necessarily CES, but they should always be safely netted. Pts with urinary/bowel disturbance 4/52 not likely to need MRI.
• Degree of neuro deficits, duration of compression and speed on onset (increased neuro deficits, long compression and fast onset = worse outcome).

Question 11

Spondylolisthesis

Answer 11

Can be anterior (CAS) - younger pop - Lytic - fracture of pars interarticularis
Or most commonly posterior (CPS) - Usually caused by age related degenerative changes

• Steppage
• Most common at C3/4 and C4/5 for CSP but much more common LSP L4/5
• Neck pain
• Referred pain in the shoulders and/or back of the head
• Pain and/or weakness in the arms, hands and/or legs and feet
• Worsening pain after periods of activity
• Nerve pain (tingling, numbness, pins & needles)
• Muscle spasms
• Reduced balance and stability

Question 12

Stenosis

Answer 12

Spinal canal too small from spinal cord and nerve roots
This can damage the spinal cord (myelopathy) and nerve roots (radiculopathy)

• Exacerbated by extension and relieved by flexion (i.e. sit to stand)
• Persistent or recurring pain in the lower back that may be described as dull, aching, or sharp.
• Weakness or difficulty in moving the legs, which can affect walking and balance.
• Neurogenic claudication
• Older age 60+
• Bi leg P or cramp with or without back pain

Causes:
RA, ossification
Spondylosis
Ligamentum flavum
Short pedicles - a condition where the bony sides of the spinal canal are shorter than normal, which can lead to a smaller spinal canal

BIlateral
Weakness\Arm P and radiculopathy
B&B changes
Wide spread clumsiness
Neck P
Difficulty in fine motor skills

Question 13

Disc

Answer 13

Nucleus pulpous is displaced from intervertebral space.
Biggest risk factor is a sedentary lifestyle and not moving.

The bigger the disc the better the prognosis of recovery.

Quadrant test: - flexion with SB will be most agg for disc herniations
Spurling’s and distraction
Upper limb tension tests

Question 14

Radiculopathy

Answer 14

Disc herniations

facet inflammation/capulsuar inflammation

Cervical spondylosis

IVF encroachment

Most commonly C7 affected - 60% then C6 - 25%

Referral:
- Poly root (multiple spinal level affected)
- Progressive (worsening neuro)
- Profound weakness (foot drop)