Spine Flashcards
1
Q
What are the top reasons for someone to see primary care
A
- 2nd: arthropathies and related disorders
- 3rd: spinal disorders
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
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
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
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
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
7
Q
What factors increase normal spinal aging process
A
- Modifiable: smoking, weight, repetitive, and steroid use
- Non-modifiable: cartilage formation, scoliosis, and age
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
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
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
11
Q
Causes of herniated nucleus pulpous (HNP)
A
- weight
- repetition
- sedentary (sitting)
- smoking
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
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
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
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
16
Q
Describe vertebral osteophytes
A
- loss of disc height
- compressive forces increase
- osteophyte formation
17
Q
Describe low back pain facet joint hypertrophy
A
- arthritis
- poor tolerance to static standing or increased lumbar lordosis
- no radicular symptoms
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
19
Q
Describe lateral spinal stenosis
A
- narrowing of the intervertebral foramina
- Symptoms: hypo reflexes, weakness of muscle
- nerve roots are being pinched
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
MOIs for spinal fractures
- 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
Detection of spinal cancer
- 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
Musculoskeletal care rule number 1 and 2 for does the patient belong in physical therapy
- 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
Metastatic organ sites to bone 'lead kettle' spelled PB-KTL
- 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
Most common sites of bone metastases (in order of frequency) from goodman box 13.5
- vertebrae (thoracic 60%/lumbosacral 30%)
- pelvis
- ribs (posterior)
- skull
- femur (proximal)
- others: sternum, cervical spine
30
Describe osteoid osteoma
- 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
Spinal metastases presentation
- 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
Osteoporosis risk factors
- 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
What stimulates bone deposition
- weight-bearing activity
- growth
- fluoride
- electricity
- more or more active osteoblasts
34
What inhibits bone deposition
- lack of weight-bearing activity
- chronic malnutrition
- alcoholism
- chronic disease
- normal aging
- hypercortisolism
35
What inhibits bone withdrawal
- 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
What stimulates bon withdrawal
- 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
Osteoporosis T-score scale
- 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
Describe T-scores
- 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
Osteoporosis clinical signs & symptoms
- 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
Describe scoliosis
- idopathic
- onset: 10-15 years of age
- females progress to greater degrees of curvature
- screening test: Adams forward bend test
41
Describe Cobb angle
- 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
What is Schroth method
- combine breathing with activation of agonist & antagonists
43
Define ankylosing spondylitis
- inflammatory disorder of unknown cause of axial skeleton
44
Risk factors of ankylosing spondylitis
- correlation between AS & HLA-B27
- second or third decade
- male
- 1/3 to 2/3 of individuals: subclinical intestinal inflammation
45
Describe spondyloarthropathies
- a group of inflammatory arthritides that are classified together
- absence of Rh factor & H:A-B27
- asymmetric oligoarthritis
- sacroilitis
- dactylitis
- enthesitis
46
Symptoms of spondyloarthropathies
- 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
Describe Psoriatic Arthritis
- a chronic inflammatory arthritis that affects 5-42% of people with psoriasis
- 3 types: asymmetric inflammatory arthritis, symmetric arthritis, and psoriatic spondylitis
48
Symptoms of Psoriatic Arthritis
- 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
