Spine 1 Flashcards
Lower Spine Vertebral Column
Lumbar
5 vertebral bodies (occasionally 6)
L1 to L5
Sacrum
5 segments (usually fused without discs)
Sacrum sits above Coccyx
3-4 segments (fused)
Ligaments of spine
Anterior Longitudinal Ligament
Connects vertebral bodies anteriorly
Posterior Longitudinal Ligament
Connects vertebral bodies posteriorly
Ligamentum Flavum (Yellow Ligament)
Connects lamina posteriorly
Lumbar Discs
general
Purpose
Cushioning between vertebral bodies
Named by Vertebral Body above and below
L4-5 disc is located between the L4 and L5 vertebral bodies
Annulus Fibrosis
Fibrous outer ring of the disc
Nucleous Pulposus
Soft inside of the disc
Spinal Cord
general
Purpose is to transmit information to and from the rest of the body
Begins at craniocervical junction and usually ends between T12-L2
End of spinal cord is called conus medullaris (conus)
At end of the conus there are spinal nerves that go to lower extremities and bowel/bladder
Cauda equina
Notice that the nerve root exits at the top of the foramen
Notice that the disc is below the nerve root
Cervical - nerve roots exiting are named based on vertebral body below foramen
Except C8 which exits in C7-T1 foramen
Thoracic to Sacral- Named for vertebral body above foramen
spine pain
Pathophysiology
neck, back, thoracic
Neck and lumbar pain more common than thoracic
Neck Pain multifactorial
Chronic stress/strains of muscle (most common) due to overuse or repetitive injuries, poor posture, acceleration/deceleration injuries, radicular pain, occupational (prolonged sitting)
Back Pain multifactorial
Lumbar strain (muscular), HNP, SS, other
Thoracic pain less common
Trauma/fracture, tumor, infection, HNP, DJD, spasm
Majority of LBP that presents to PCP is non-specific in etiology, primarily musculoskeletal in origin
Resolves with conservative measures within a few weeks
Less than 1% will have serious systemic condition
Cervical Spine
Spurling Test
to diagnosis cervical HNP or spondylosis
Patient seated, laterally flex head, apply slight pressure downward to increase axial load
+ if numbness, tingling, it pain down ipsilateral side
Cervical Spine
Hoffman Reflex
to test for long tract spinal cord involvement in neck
Pathological reflex, indicates abnormality within the cervical spinal cord or higher (UMN lesion or pyramidal sign) ALS, MS, spinal cord compression
(+) reflex is flexion and adduction of the thumb/index finger after flicking of the middle finger
lumbar
Tests
Gait (barefoot) look at Trendelenburg (pelvis level on one foot = normal hip abductor)
Heel and toe walking (tests L4-5, S1 innervated muscles)
Calf and thigh circumference? atrophy
Special Testing
Seated SLR, supine SLR, slump test
Seated SLR - + test causes patient to lean back
Supine SLR (Lesegue) - + test is radicular pain in leg, not back (HNP or compression) symptoms at 20 degrees or less is suggestive of symptom amplification
Slump test – seated, hands behind back, then slump in relaxed position, chin to chest. Extend leg, dorsiflex fully. Examiner gives slight pressure to back of head. + test is impingement on dura, spinal cord or nerve roots.
back pain
PE
Additional Components of Examination
Should include:
Deep Tendon Reflex Examination of patella, ankle, ? Clonus, ? Babinski
Sensory Examination (light touch/pin prick) to help identify/localize a lesion and determine extent of deficit
Evaluation of gait
Back pain
red flags
Fever, chills, weight loss
History of IV drug abuse
History of malignancy
Progressive weakness
Bowel or bladder dysfunction
Trauma
Increasing pain not controlled by simple analgesia
Saddle anesthesia
Distended/palpable bladder
Paraparesis
Unexplained Neurological deficit
Decreasing pain in the face of increasing deficit
Myelopathy
Injury/ compression of the spinal cord
Radiculopathy
Injury/ compression of the nerve root
Stenosis
Narrowing of passage for spinal cord or nerve root
Acute LBP-Sprain or Strain
general
LBP is a symptom, not a diagnosis
Strain implies injury to paravertebral spinal muscles
Sprain describes ligamentous injuries +/- involving facet joints or annulus fibrosis (without HNP- herniation of …)
Patients give history of repeated lifting, twisting, or operation of vibrating equipment
Risk factors include poor fitness, smoking, job dissatisfaction, psychosocial factors
LBP Sprain or Strain
Clinical Symptoms and red flags
Acute onset of symptoms, often trivial event such as lifting, leaning
Pain can radiate to buttocks, difficulty standing erect
Red flags –Neurologic deficits, fever/other constitutional symptoms (weight loss, B/B dysfunction), unresponsive pain syndromes, trauma, pain at rest,
LBP Sprain or Strain
exam and imaging
Exam: Diffuse tenderness low back or SIJ, reduced ROM, Intact MMST and reflexes
Imaging: x-rays not helpful, MRI not indicated
Defer x-rays first 2-6 weeks
LBP strain/sprain
Tx phases
LBP without radicular features and no focal neurological deficits:
Phase 1: Focus on symptomatic relief
Avoid intense physical activity
Pain management (NSAIDS, acetaminophen, etc.), topical treatments (heat, massage, acupuncture). Avoid muscle relaxants, steroids, narcotics
80-90% of LBP episodes resolve within 2-6 weeks
Phase 2: After acute pain resolves help patient return to full activity
Return to work issues
PT for exercise program, aerobic activity
Refer to specialist for symptoms >4 weeks
Degenerative Disc Disease
general
Age or activity related breakdown of disc material; leads to reduction of fluid within the disc and thinning of the disc which then leads to osteophyte formation
Common complaints/ symptoms:
May be nothing or may be pain, numbness, tingling, etc
Depends on what other problem the DDD causes
Pain worsens with sitting
Aging, obesity, smoking, and excessive axial loads can accelerate the degeneration
Degenerative Disc Disease
imaging
Tests:
x-rays will show disc space narrowing and possibly osteophyte formation
MRI is needed if patient has symptoms of nerve involvement
Will also show disc desiccation and osteophytes
Degenerative Disc Disease
Tx
Nothing if there is no pain
Reduce accelerators
Treat the pain with NSAIDs, bracing * and PT for core strengthening
Surgical intervention should be reserved for cases with severe pain or nerve impingement (usually spinal fusion)
Disc Bulge/ Disc Herniation
general
extrusion and sequestration
Bulge: large amount of annulus creeps out of its normal space
Herniation: smaller but more intense amount of annulus creeps out of its normal space
Extrusion: annulus tears because of degeneration and what is left of the nucleus leaks out
Sequestration: extrusion that is completely severed
Disc Bulge/ Disc Herniation
S/Sx
Pain
Numbness or tingling
Weakness
Typically worse symptoms with herniation
Disc Bulge/ Disc Herniation
PE and imaging
(+) Straight leg raise
DTRs- normal or limitted if nerve involvement ( would only be unilateral)
AROM- normal or limitted if nerve involvement ( would only be unilateral)
Tests:
X-rays can be unremarkable
MRI is test of choice and will typically show posterolateral bulge or herniation
Disc Bulge/ Disc Herniation
Tx
Bulge: NSAIDs, bracing, PT, steroid injections
Herniation: surgery to remove portion of disc that is causing nerve compression
bulge will often resolve on its own within a few months but herniation needs surgery to repair fairly quickly to try to prevent permanent nerve damage
Cauda Equina Syndrome
general
Posterior compression of nerve tissue (cauda equine) and not posterolateral compression of nerve roots (can come from fracture fragments, disc herniation, hematoma, abscess)
Cauda Equina Syndrome
symptoms
Cauda Equina Syndrome
PE and imaging
bowel and/or bladder dysfunction
decreased rectal tone
saddle anesthesia (sensory deficit over the perineum, buttocks, and inner thighs)
variable motor and sensory loss in the lower extremities
decreased lower extremity reflexes
sciatica
Tests:
MRI (of entire spine if concern that it is related to metastasis, there is a chance of another mass)
ONE OF THE FEW TIMES IN LIFE THAT MRI IS ALLOWED TO BE ORDERED STAT/ EMERGENTLY
Cauda Equina Syndrome
Tx
Treatment:
Steroids FAST; dexamethasone 10mg IV
Consult neurosurgery ASAP
Misc:
Often with this disease, once a symptom presents, it is unlikely to resolve with surgery… you are just trying to prevent more problems and hoping to slightly improve current symptoms
Facet Arthritis
general
Degenerative changes of the facet joints related to aging and overuse
facet arthritis
Common complaints/ symptoms:
Same as all other OA
Pain
Stiffness
Can also have numbness and other radicular symptoms
facet arthritis
PE and imaging
PE:
Improved pain with forward flexion
Worsening of pain with extension and hyperextension
Tests:
Might see on x-rays but difficult
Easiest to see on MRI or CT
