Spine

Question 1

What is the normal alignment of the spine?

Answer 1

cervical lordosis = curve in
thoracic kyphosis = curve out
lumbar lordosis = curve in

Question 2

Kyphosis is excessive ______________ curvature of the spine. It is abnormality in the _____________ plane

Answer 2

outward “rounding of the back”
saggital

Question 3

What are the 5 different types of kyphosis?

Answer 3

1. congenital
2. postural- secondary to ligamentous and musculature weakness due to change in alignment
3. metabolic/nutritional- loss of calcium/bone density - osteopenia/ osteoperosis
4. post traumatic or post surgical
5. Scheurman’s - wedge shaped vertebra that develops in adolescents (trapezoid bone shape results in kyphosis)

Question 4

The gold standard to measure kyphosis is

Answer 4

a cobb angle

Question 5

Imaging and treatment options for kyphosis

Answer 5

imaging
XR is first - full spine view of “scoliosis” films which are completed standing
CTs for trauma/surgery
DEXA- bone density

Tx: most common is surveillance or monitoring

Question 6

What is the most common type of adult scoliosis ?

Answer 6

thoracolumbar

Question 7

Scoliosis is abnormality in the ________________ plane. Spinal deformity with a cob angle of _______________ in mature adult. It is due to ___________________ or secondary to hip/knee pathology resulting in _________________, __________________

Answer 7

coronal
> 10 degrees
asymmetric disc degeneration
asymmetric loading
osteoporosis

Question 8

What is the workup for scoliosis?

Answer 8

full spine XR (AP, Lat) often include flexion/extension to look for instability as affected levels.
CT if fracture or true bony abnormality presumed
MRI if pt has functional symptoms, radicular symptoms (very common), new weakness, loss of sensation, concern for spinal cord compression
DEXA > 60 y/o

Question 9

Clinical evaluation of pt who presents with back pain

Answer 9

1. axial loading, back/neck pain
2. symptoms of spinal stenosis (central or radicular)
3. most pts have worse pain when upright and walking. pain can be from nerve impingement but also from paraspinal muscles and pelvis trying to correct the imbalanced alignment
4. fatigue, extreme muscle pain

Question 10

The more invasive treatments for scoliosis are based on symptomology. What are the options?

Answer 10

1. facet injections ( back pain) +/- ablations = back pain
2. Transforaminal ESIs
3. trigger point injections to paraspinal musculature for pain

Surgical intervention is reserved for pts with progressive deformity (changes in cobb angle/lateralized curveature over time, intractable pain, failure to improve with conservative measures, neurologic deficits
1. no instability = laminotomies/laminectomy- risk of further progression of curveature
2. Requires larger segmental interbody instrumented fusion for alignment correction

Question 11

Muscle Power
0- zero
1-trace
2-poor
3- fair
4- good
5- normal

Answer 11

0-zero: no muscle contraction is seen
1-trace: flicker or trace of contraction is seen
2: poor: active movement only when gravity is removed
3-fair: active movement against gravity but not resistance
4- good: active movement against gravity with SOME resistance
5- normal: active movement against gravity with full resistance

Question 12

Nerve root motor function

Answer 12

C5 elbow flexion
C6 wrist extension
C7 wrist flexion, finger extension
C8 finger flexion
T1 finger abduction
L1, 2 hip abduction
L3, 4 knee extension
L5, S1 knee flexion
L5 great toe extension
S1 great to flexion

Question 13

Root values for tendon reflexes

Answer 13

C5 biceps
C6 brachioradialis
C7 triceps
L3,4 quadriceps
L5, S1 achiles tendon

Question 14

Spondylosis is a type of degenerative spine disease. It is ___________________ loss of ______________ which results in bone change over time. This can lead to bone spurring, osteophyte formation, or stenosis. It is often referred to as ____________________ which is another umbrella term for degeneration of intervertebral disc space and joints.

What are the symptoms? Often _______________ is not usually symptomatic due to rigidity of the spine and width of canal.

What is the workup?

Answer 14

age related
disc height
osteoarthiritis

symptoms: neck pain, back pain, stiffness (Loss of ROM), radiculopathy, numbness, parasthesias, weakness,
myelopathy: sxs of spinal cord compression

thoracic spondylosis

Workup:
XR first- localized regions of spine based on areas of discomfort (C/L/T). often see vacuum disc phenomena when progressed or bone on bone changes

Question 15

Most common areas of spondylosis

Answer 15

cervical/lumbar spine

Question 16

Spondyloisthesis is the _______________ of one vertebral body onto another. The most common is that the ____________ slips forward to the __________________. The most common area is ______________, second is ________________. Can occur in adolescents with congenital ____________. Isthmic spondyloisthesis or spondyloysis = failure to complete the ______________ = defect in pars bilaterally.

what causes this?

Answer 16

anterior subluxation
vertebral body, inferior body
L5-S1, L4-5
pars defects
neural arch

cause: repetitive hyperextension of the lumbar spine (gymnasts, pitchers, football, etc)

Question 17

What are the symptoms of spondylolisthesis? Its important to ask **when the pain occurs ** It is frequently _____________. If associated with stenosis (very common) can have symptoms of ___________________.

What is the workup?

Answer 17

back pain, neck pain.
mechanical- bending, flexion/extension moves or twisting
nerve compression

workup: XR, standing, flexion and extension are required to see the slip
CT,MRI +/- DEXA

Question 18

_______________ refers to narrowing of the neural spaces in the spine which results in nerve root compression or ______________, thecal sac or spinal cord compression. This can occur in any area of the spine.

Answer 18

stenosis
“pinched nerve”

Question 19

What are the different types of spinal stenosis?

Answer 19

1. cervical spinal stenosis
   - results in cervical radic/myelopathy (UELE)
2. thoracic stenosis
   -results in thoracic radic/myelopathy
3. Lumbar stenosis
   central- if severe can cause neurogenic claudication
   lateral recess- affects transversing nerves
   foraminal- affects existing nerves

Question 20

Stenosis can be caused by hypertrophy of ligamentum flavum, hypertrophy of facet joints. All results in ________________________. The most common associated with degenerative changes in setting of __________________. Most common levels of lumbar spine are ________________ and _______________

Answer 20

compression of the nerves/cord in some manner.
congenital narrowing
L4-5, L3-4

Question 21

Presentation/clinical manifestations of spinal stenosis

Answer 21

1. back pain or neck pain
2. radicular symptoms secondary to corresponding nerve root impingement. often multilevel symptoms
3. melopathy
4. **gradually progressive back pain and leg pain thats worse with standing/walking but improved with flexion and lying down **
   shopping cart sign= patients can improve distance and functionality but slight flexed posture. or patients can ambulate further with walker.
5. Neurogenic claudication- stenosis caused by neuro deterioration with when upright or with movement (lumbar issue only) pain not always present.
   -heaviness in legs

Question 22

For stenosis, ________________ is the most specific test to identify nerve compression

Answer 22

MRI

Question 23

In the case of Spondylosis, spondyloisthesis, and spinal stenosis, If theres spinal cord compression, intervention is recommended sooner especially in patients with worsening __________________.

Answer 23

myelopathy

Question 24

For the management of Spondylosis, spondyloisthesis, and spinal stenosis…

1. Foraminotomies can be performed ___________________
2. Laminectomies are most common in _____________________ for ______________ and _____________ that is not associated with ___________________
3. Interbody fusions (ALIF, TLIF, XLIF, OLIF, PLIF) with instrumentation to correct alignment _______________________, ______________________, ____________________, and ______________ - LAST RESORT

Answer 24

1. C/T/L spine
2. T/L spine for spondylosis and stenosis, spondyloisthesis or instability.
3. sagittal, coronal plane deformities, spondylosis, unstable spondylolisthesis, and stenosis

Question 25

Herniated nucelus pulposus aka disc herniation presents as displacement of the nucelus pulposus beyond the _________________________. The disk anatomy consists of 2 main structures: 1. 2. The nucleus pulposus is composed of water, type II collage, chondrocyte like cells, and proteoglycans (crab meat) which allows ______________________________.

Answer 25

intervertebral disc space. 1. nucleus polpusus (NP) 2. annulus fibrosis (AF) allows the disc to be elastic, flexible under stress forces and to absorb compression

Question 26

The nucleus pulposus/disc hernation is the most common cause of ______________________ and one of the most common indications for _______________________. Typically, _____________ is affected BUT can be _______________ if large or two components. Often, leg pain is worse when ______________ or slightly ______________ posture (different than stenosis). Working positions with lifting requirements or loading, genetic predisposition, connective tissue disorders that affect quality of disc. MC between 30-50 y/o. M> F.

Answer 26

sciatic pain, spine surgery one nerve multiple seated, slightly flexed

Question 27

__________ is the gold standard imaging for nucleus pulposis/disc hernation.

Answer 27

MRI

Question 28

What is the treatment for nucleus pulposis/disc hernation?

Answer 28

TIMEEEEE!!!!!! 60-80% of disc herniations will resorb or resolve within a 9-12 months period and DO NOT require surgery. PT Steroids are first line - prednisone/decadron Neuropathic meds are next line - neurontin, lyrica, cymbalta, TCA ESIs/TESIs Surgery: lumbar= microdisectomy is primary treatment for pts with acute HNP with deficits or severe pain. cervical= cannot access disc post due to spinal cord, need to go ant via ACDF or disc replacement Thoracic- post approach may/may not require full laminectomy vs hemilaminectomy depending on size and location.

Question 29

Complications of nucleus pulposis/disc hernation

Answer 29

1. compression effect on nerve root = motor deficits - the longer the nerve root has been affected, the LESS likely it will regain full function. >1 yr prognosis is poor prognosis. - in C/T spine = risk of compression = neuro sx = rare 2. cauda equina syndrome- COMMON- results from lumbosacral nerve root compression with possible bowel or bladder dysfunction. This is considered an ABSOLUTE indicate for acute surgical resolution and early decompression is associated with symptoms of improvement.

Question 30

Cauda Equina syndrome is caused by compression, trauma, or damage to multiple nerves of the cauda equina. __________________ is the most common.

Answer 30

lumbar disc herniation

Question 31

Cauda Equina MUST include all of these symptoms: (6) This is a highly litigated condition that needs to be recognized IMMEDIATELY. Order a STAT ____________, STAT ______________ or ortho spine consult.

Answer 31

1. weakness in LE 2. saddle anesthesia 3. urinary retention (can have incontinence) 4. bowel incontinence 5. hyporeflexia or aflexia 6. pain MRI, NSGY

Question 32

You cannot have TRUE cauda equina without ___________________. This should be treated within _________ MAX or patients will be left with permanent deficits.

Answer 32

weakness. 24

Question 33

Cervical strain is strain on the ___________, ___________ and _____________ of the neck (tear). It is one of the most common MSS issues seen in clinical setting. It is most commonly seen after __________ or other traumatic events that cause sudden flexion/extension of the neck (whiplash innjury)

Answer 33

muscle, fascia, tendon MVA

Question 34

What are the symptoms of a cervical strain?

Answer 34

neck pain, HA. shoulder, scapular and or arm pain, visual disturbances, tinnitus, dizziness, concussion, difficulty sleeping due to pain, disturbed concentration and memory, decreased ROM/stiffness or rigidity

Question 35

What is the workup and treatment for a cervical strain? Who is surgery only reserved for?

Answer 35

1. XR- should be used to r/o fractures 2. MRI- *ideal* to show posterior ligamentous edema (interspinous ligaments commonly affected) seen on STRI signal view of MRI or edema with paraspinal musculature. Tx: Early rehab/PT Soft collar NSAIDs, muscle relaxants, sleep aids trigger points, medial branch blocks, RFA botox= spasticity accunpunture surgery is only reserved for cervical strain associated with disruption of disc spaces or disruption of PLC causing instability

Question 36

Lumbar strain is strain of the muscle, fascia, tendon of the lower back. The most common causes of LBP among athletes are 1. 2. these occur mainly at the lumbosacral level. This injury occurs during _________ activities which can temporarily cause instability of the spine, causing injury to surrounding tissues. The ___________ and ______________ areas tend to bear the highest loads and tend to undergo the most motion so they tend to sustain the most spinal strain/sprain injuries.

Answer 36

1. musculoligamentous sprains 2. musculoligamentous strains load bearing L4-5, L5-S1

Question 37

In a lumbar strain, deficits in the afferent or efferent pathways of proprioceptors are known risk factors for _______________. Prior structural deformities such as scoliosis, spondylosis or spinal fusions may predispose to a spinal strain.

Answer 37

spinal soft tissue injuries

Question 38

Nonradiating back pain is asssociated with ____________________

Answer 38

mechanical stress

Question 39

Sprains are _______________ injuries that are caused by sudden violent contraction, torsion, severe direct blows, forceful straightening. The ______________________ are most prone to injury.

Answer 39

ligamentous posterior ligaments

Question 40

Strains are defines as tears, either partial or complete of the muscle ________________. These most frequently result from a violent muscular contraction during an excessively forceful muscular stretch. The most susceptible muscles are those that _________________

Answer 40

tendon unit span several joints

Question 41

Presentation of a lumbar strain

Answer 41

1. LBP 2. pain exacerbated by standing, twising, active contractions and passive stretching 3. focal tenderness commonly localized over the posterior lumbar spinal muscles lateral to the SPs or at the inertion of the muscle at the iliac crest. 4. reduced ROM 5. if presenting with radicular pain into the LE, have to think about some form of disc injury (HNP or nerve compression)

Question 42

Symptoms for lumbar strains usually decrease after _____________ and they should subside between _______________

Answer 42

7-10 days 1-6 weeks

Question 43

TX for lumbar strain when is surgery indicated?

Answer 43

1. early rehab/ PT 2. heat/ice, electrical stimulation, massage, myofascial release, traction 3. bracing 4. NSAIDs, muscle relaxants, sleep aids 5. trigger point, facet, medial branch blocks, RFA 6. botox for spasticity 7. accupuncture 8. surgery for lumbar srtrain associated with disruption of disc spaces or disruption of PLC causing instability

Question 44

How do compression fractures occur? How does the patient typically present? F>M, and osteoperosis are RF

Answer 44

when theres a crack in the cortex of the bone occurs, causing loss of height, which can lead to severe pain and deformity. Pt has sudden onset of back pain (usually worse when upright as compared to lying down)

Question 45

Where do compression fractures commonly occur?

Answer 45

T spine- thoracolumbar junction due to high level of mobility

Question 46

Compression fractures are typically stable fractures, what does this mean?

Answer 46

PLC intact and <2 column injuries

Question 47

How do compression fractures tend to heal?

Answer 47

in elderly- loss of height with softer bones bones compress further and eventually hardening/healing as they turn sclerotic. the softer the bones are, the more loss of vertebral body height a patient may experience.

Question 48

A compression fracture can be caused by MINIMAL trauma or even small bump in elderly with very soft bones. If osteoporotic and have 1 compression, compression fracture is 5x more likely. Consider METS in pts < 55 and no hx of trauma. What is the tx?

Answer 48

brace x 3 weeks serial XR/CT PT after bracing if needed (recommended for elderly) TREAR OSTEOPEROSIS kyphoplasty- inj of cement into vertebral body to reduce further loss of height. ORIF or VBF if alignment is compromised +/- decompression if nerve impingement is present (rare)