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Clinical Medicine II > Spine > Flashcards

Spine Flashcards

1
Q

What are the top reasons for someone to see primary care

A
  • 2nd: arthropathies and related disorders
  • 3rd: spinal disorders
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2
Q

What was to old approach to seeking care

A
  • initial meeting might not happen for up to a month, and then there is no set procedure for treatment
  • initial meeting with doctor
  • patient might see a specialist
  • patient might undergo diagnosis
  • patient follows up with doctors
  • physical therapy
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3
Q

What is the new approach to seeking care

A
  • immediately see physical therapist to initiate evidence-based conservative program
  • physical therapy
  • patients with complicated back pain are sent for additional treatment
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4
Q

First triage for low back pain at first contact provider

A
  • Medical Management (red light): “red flags”, medical comorbidities precluding rehab, and leg pain with progressive neurologic deficits
  • Rehab Management (yellow light): medium to high psychosocial risk status, low psychosocial risk status with predominantly leg pain, and minor or controlled medical comorbidities
  • Self-Care Management (green light): low psychosocial risk status, predominantly axial low back pain, and minor or controlled medical comorbidities
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5
Q

Non-mechanical low back pain

A
  • Neoplasia: spine tenderness and weight loss
  • Inflammatory arthritis: morning stiffness and improves with exercise
  • Infection: spine tenderness and constitutional symptoms
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6
Q

Non-Spinal/Visceral Disease

A
  • Pelvic organs: lower abdominal symptoms common
  • Renal organs: usually involves abdominal symptoms and abnormal urinalysis
  • Aortic aneurysm: epigastric pain and pulsatile abdominal mass
  • Gastrointestinal system: epigastric pain and nauseas & vomiting
  • Shingles: unilateral, dermatomal pain, and distinctive rash
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7
Q

What factors increase normal spinal aging process

A
  • Modifiable: smoking, weight, repetitive, and steroid use
  • Non-modifiable: cartilage formation, scoliosis, and age
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8
Q

Common problems for musculoskeletal pathology of low back pain

A
  • HNP
  • arthritis
  • stenosis
  • osteoporosis & vertebral fractures
  • scoliosis
  • osteochondritis
  • autoimmune related: AS and DISH
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9
Q

Describe disc pressure and nucleus movement

A
  • Disc nucleus moves posterior in flexion & anterior in extension
  • Standing = 100% disc pressure
  • Supine = <25% disc pressure
  • Sidelying = 75% disc pressure
  • Flexion standing = 150% disc pressure
  • Flexion sitting = 85% disc pressure
  • Flexion sitting & lifting = 275 % disc pressure
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10
Q

What are the 3 stages of disc degeneration

A
  • Stage 1 dysfunction: tears in the annulus, hyper mobility of facet joints
  • Stage 2 instability: disc reabsorption, degeneration of facet joints with capsular laxity, & subluxation
  • Stage 3 stabilization: osteophyte formation, stenosis
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11
Q

Causes of herniated nucleus pulpous (HNP)

A
  • weight
  • repetition
  • sedentary (sitting)
  • smoking
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12
Q

Symptoms of herniated nucleus pulpous (HNP)

A
  • early onset: sharp pain
  • later onset: pain goes away but then we get numbness or some motor problems as well
  • Bulging disc: protruding a little bit but think it can be moved a little bit
  • Sequestered disc: has pushed through the disc & into the spinal canal & it’s stuck there
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13
Q

Describe degenerative disc disease (DDD)

A
  • microscopic changes in the discs begin at 30 years old
  • nucleus decreases in GAG = decreased hydration (70% by 40 y/o)
  • nucleus changes from type 2 collagen to type 1 & begins to function more like annulus
  • decreased disc height & weight bearing through vertebrae = osteophytes formation
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14
Q

Symptoms of degenerative disc disease (DDD)

A
  • gradual onset of pain
  • intermittent & recurring pain over several years
  • pain increases with activity or static positioning
  • stiffness
  • pain into buttock/sclerotome
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15
Q

Define sclerotome

A
  • the part of each somite in a vertebrate embryo giving rise to bone or other skeletal tissue
  • cartilage of the ribs & vertebral body
  • unique pain referral pattern
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16
Q

Describe vertebral osteophytes

A
  • loss of disc height
  • compressive forces increase
  • osteophyte formation
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17
Q

Describe low back pain facet joint hypertrophy

A
  • arthritis
  • poor tolerance to static standing or increased lumbar lordosis
  • no radicular symptoms
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18
Q

Describe central spinal stenosis

A
  • narrowing of the spinal canal
  • Symptoms: hyper reflexes, Babinski (toes go up for normal)
  • spinal cord is being pinched
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19
Q

Describe lateral spinal stenosis

A
  • narrowing of the intervertebral foramina
  • Symptoms: hypo reflexes, weakness of muscle
  • nerve roots are being pinched
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20
Q

Clinical prediction rule for lumbar spinal stenosis

A
  • bilateral symptoms
  • leg pain > back pain
  • pain during walking or standing
  • pain relief upon sitting
  • age > 48 years old
21
Q

Describe low back pain spondylolithesis

A
  • Spondylolysis: defect of pars interarticular (crack)
  • Spondylolithesis: bilateral defect with displacement of the superior vertebra (pars defect = scotty dog)
  • 5 types underlying cause of defect
  • 4 grades of movement describe amount of displacement
22
Q

What are the 5 types of spondylolithesis

A

-Type I: congenital malformation of sacrum/L5
- Type II: isthmic spondylolithesis, mechanical stress leads to stress fracture at par interarticularis
- Type III: degenerative (older)
- Type IV: traumatic, casting
- Type V: pathologic (tumor)

23
Q

What are the 4 grades of spondylolithesis

A
  • normal spine
  • Grade 1: <25% slippage
  • Grade 2: 25-50% slippage
  • Grade 3: 50-75% slippage
  • Grade 4: >75% slippage
24
Q

Treatment for the different grades for spondylolithesis

A
  • Grade 1: usually not symptomatic
  • Grade 2: education to avoid extension & begin spinal stabilization, may use casting to reduce anterior shear forces & allow healing
  • Grade 3: conservative treatment may be attempted
  • Grade 4: surgery due to neurological involvement
25
Q

MOIs for spinal fractures

A
  • hyper flexion: diving fracture, results in disruption of posterior lateral ligament and tear-drop fracture
  • hyper extension: MVC striking windshield, results in “Hangman’s fracture”
  • Axial compression: force to vertex of head, results in burst fracture of atlas (AKA Jefferson fracture)
26
Q

Detection of spinal cancer

A
  • Age > 50
  • Unrelenting night pain or pain at rest
  • Progressive motor or sensory deficit
  • Unexplained weight loss
  • Failure to improve with conservative care
  • PRIOR history of Cancer
27
Q

Musculoskeletal care rule number 1 and 2 for does the patient belong in physical therapy

A
  • Rule No. 1: normal musculoskeletal conditions should directly respond proportional to a mechanical stimulus, i.e. dose response curve (the more we do the more it is aggravated)
  • Rule No. 2: lack of improvement with musculoskeletal care (following rule No.1) suggests non-musculoskeletal pathology as source of symptoms = exam vigilance
28
Q

Metastatic organ sites to bone ‘lead kettle’ spelled PB-KTL

A
  • P: prostate
  • B: breast
  • K: kidney
  • T: thyroid
  • L: lung
  • by gender 80% of cancer spread from: females breast and lungs; males prostate lung
29
Q

Most common sites of bone metastases (in order of frequency) from goodman box 13.5

A
  • vertebrae (thoracic 60%/lumbosacral 30%)
  • pelvis
  • ribs (posterior)
  • skull
  • femur (proximal)
  • others: sternum, cervical spine
30
Q

Describe osteoid osteoma

A
  • benign (non-cancerous) bone tumor that usually develops in the long bones of the body, such as the femur & tibia
  • unknown & does not spread
  • most likely in children & young adults age 4-25
  • males 3x > females
31
Q

Spinal metastases presentation

A
  • Sudden onset of back pain: pathologic fracture, not a reaction to loading response
  • Gradual worsening of back pain: might not have fully developed yet (gotten to the pathological fracture)
32
Q

Osteoporosis risk factors

A
  • female gender
  • older age (65+)
  • ethnicity: caucasian & asian
  • family history
  • prior fracture after age 50
  • diet for vitamin D
  • physical activity
  • tobacco use
  • medications: Glucocorticoids, Anti-seizure drugs, & Thyroid hormone
  • low body weight
33
Q

What stimulates bone deposition

A
  • weight-bearing activity
  • growth
  • fluoride
  • electricity
  • more or more active osteoblasts
34
Q

What inhibits bone deposition

A
  • lack of weight-bearing activity
  • chronic malnutrition
  • alcoholism
  • chronic disease
  • normal aging
  • hypercortisolism
35
Q

What inhibits bone withdrawal

A
  • weight-bearing activity
  • estrogen
  • testosterone
  • calcitonin
  • adequate vitamin D intake
  • adequate calcium intake (mg/day)
  • child: 400-700
  • adolescent: 1000-1500
  • adult: 750-1000
  • pregnancy: 1500
  • postmenopause: 1500
36
Q

What stimulates bon withdrawal

A
  • more or more active osteoclasts
  • lack of weight-bearing activity
  • space travel (weightlessness)
  • hyperparathyroidism
  • hypercortisolism
  • hyperthyroidism
  • estrogen deficiency
  • acidosis
  • myeloma
  • lymphoma
  • inadequate calcium intake
  • normal aging
37
Q

Osteoporosis T-score scale

A
  • Normal: -1.0 or above: T-score is within 1 SD of the young adult reference mean
  • Osteopenia (low bone mass): -1.0 to -2.5: T-score is 1.0-2.5 SDs below young adult mean for age
  • Osteoporosis: -2.5 or less: T-score is 2.5 or more SDs below mean for age
  • Severe osteoporosis: -2.5 or less with one or more fragility fractures: BMD is 2.5 or more SDs below mean for age
38
Q

Describe T-scores

A
  • measured by DXA (dual energy x-ray absorptiometry) and CT (computerized tomography)
  • -2.5 is the cutoff for osteoporosis
  • -1to -2.5: bone loss has occurred or lack of peak development, check for OP causes
39
Q

Osteoporosis clinical signs & symptoms

A
  • back pain: episodic, acute low thoracic/high lumbar pain
  • compression fracture of the spine (postmenopausal osteoporosis)
  • bone fracture (age-related osteoporosis)
  • decrease in height (more than 1 inch shorter than max adult height)
  • kyphosis (Dowager’s hump)
  • decreased activity tolerance
  • early satiety
40
Q

Describe scoliosis

A
  • idopathic
  • onset: 10-15 years of age
  • females progress to greater degrees of curvature
  • screening test: Adams forward bend test
41
Q

Describe Cobb angle

A
  • the angle between the perpendiculars of the upper and lower most vertebra
  • > 10 degrees = positive scoliosis diagnosis
  • 25-30 degrees = significant curve: conservative care, schroth method
  • 45-50 degrees = severe & surgery
42
Q

What is Schroth method

A
  • combine breathing with activation of agonist & antagonists
43
Q

Define ankylosing spondylitis

A
  • inflammatory disorder of unknown cause of axial skeleton
44
Q

Risk factors of ankylosing spondylitis

A
  • correlation between AS & HLA-B27
  • second or third decade
  • male
  • 1/3 to 2/3 of individuals: subclinical intestinal inflammation
45
Q

Describe spondyloarthropathies

A
  • a group of inflammatory arthritides that are classified together
  • absence of Rh factor & H:A-B27
  • asymmetric oligoarthritis
  • sacroilitis
  • dactylitis
  • enthesitis
46
Q

Symptoms of spondyloarthropathies

A
  • enthesis = connective tissue between tendon or ligament & bone
  • sacroiliitis, earliest manifestation
  • radiographic sign of “bamboo spine”
  • diffuse osteoporosis
  • erosion of vertebral bodies at the disk margin
  • “squaring” of vertebrae
  • inflammation & destruction of the disc-bone border
47
Q

Describe Psoriatic Arthritis

A
  • a chronic inflammatory arthritis that affects 5-42% of people with psoriasis
  • 3 types: asymmetric inflammatory arthritis, symmetric arthritis, and psoriatic spondylitis
48
Q

Symptoms of Psoriatic Arthritis

A
  • morning stiffness
  • PIP & DIP with characteristic sausage shaped digits
  • 50% develop spondylitis & the other half have sacroiliitis
  • enthesitis at the achilles tendon, plantar fascia, and pelvic bones
  • tenosynovitis of the flexor tendons of the hands, & extensor carpi ulnaris

Clinical Medicine II (21 decks)

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