Spine Flashcards
where is the problem
-Use a pain diagram
-Does it follow a radicular pattern? -> nerve root vs not
-Does it follow a pattern of referred pain?
-Mechanical symptoms?
Red flags
-Is the pain primarily in the back of the leg? -> sciatica
-Bowel or bladder incontinence? -> cauda equina
-Sexual dysfunction? -> cauda equina
Non-dermal or non-anatomic patterns? (e.g..M.S., Lyme, Fibromyalgia)
-DM -> peripheral neuropathy
muscle strength grading
(didnt go over it)- told us to look on our own
grading reflex
-0= absent
-1+ = hyporeflexic
-2+ = normal
-3+ = hyperreflexia
-4+ = clonus
C5, C6, C7, C8, L4, L5, S1 -> KNOW THIS
-5,6,7- MC pathology here
-motor, reflex, sensation
-C5- deltoid raise, bicep curl, bicep tendon reflex, bicep
-C6- bicep curl, wrist extension, brachioradialis
-C7- triceps, middle finger reflex
-C8- no reflex, sensation ulnar aspect of hand
-L4- tibialis anterior (supinate foot), patellar reflex, inside of foot sensation
-L5- lift big toe, no reflex, sensation is the top of the foot
-S1- Achilles reflex, lateral aspect of the foot sensation
spurling test
-Ask the patient to extend the neck while tilting the head to the side. This narrows the neural foramen and will reproduce radicular arm pain with cervical disk herniations or cervical spondylolysis
axial loading
-with pt standing -> push down on their head
-may provoke neck pain in pts with disk pathology
hoffman reflex
-pts hand relaxed -> flick the long finger nail and look for index and thumb flexion -> sign of upper motor neuron interruption (e.g. cervical herniated disk or stenotic lesion)
superficial abdominal reflex
-pt supine
-Stroke lightly toward the umbilicus.
-Normal = movement of the umbilicus is toward the stimulated side
-Absence of this may suggest spinal cord pathology in the cervical or thoracic region.
-Perform in uppear & lower quadrants on both sides
ankle clonus
-with pt seated, dorsiflex the ankle suddenly and observe for rhythmic beating (clonus)
-Sign of long-tract spinal cord involvement (descending/motor)
straight leg raising
-Places the L5, S1, & sciatic nerves under tension.
-Patient supine
-Elevate the leg approximately 80 deg
-Positive if pt has pain radiating down leg
-pain PAST THE KNEE
cross leg straight leg raise test
-Supine and raise uninvolved leg
-A greater degree of elevation is usually required
-Pain will radiate on leg not being raised
reverse straight leg raise
-Places L1-4 nerve roots under tension
-Pt is prone and the hip is lifted into extension while keeping the knee straight
-Increased pain suggests compression of upper lumbar nerve roots
common spinal conditions <10yo
-Congenital Kyphosis
Scoliosis
Intervertebral diskitis
Myelomeningocele- backbone and spinal canal do not close before birth -> type of spina bifida
Osteoblastoma- tumor that replaces bones with osteoid -> benign
Leukemia
spinal cord
-ascending fibers- deliver deep touch and vibration, proprioception
-lateral spinothalamic tract- pain and temp (ascending)
-lateral corticospinal tract- voluntary muscle contraction (descending)
common spinal conditions: 11-19yo
-spondylolisthesis
-kyphosis (scheuermanns disease)
common spinal conditions: 20-29yo
-disk injuries (central disk protrusion, disk sprain)
-spondylolisthesis
-spinal fracture
common spinal conditions: 30-39yo
-cervical and lumbar disk herniation or degeneration
common spinal conditions: 40-49yo
-cervical and lumbar disk herniation or degeneration
-spondylolisthesis with radicular pain
common spinal conditions: 50-59 yo
-disk degeneration
-herniated disk
-metastatic tumors- bone pain that keeps the pt up
common spinal conditions: >60yo
-Spinal stenosis
-Disk degeneration
-Herniated disk
-Spinal instability
-Metastatic tumors
common terms
-Radiculopathy
-Dysfunction of a nerve root
-Signs & Symptoms: Pain in the distribution of that nerve root
-Dermatomal sensory disturbances.
-Weakness of muscle innervated by that nerve root.
-Myelopathy
-Abnormal condition of spinal cord through ds or compression
-Usual consequences are spasticity, impairment of sensation, & impairment of bowel or bladder function
-Mechanical Pain
-AKA musculoskeletal back pain
-MC form of back pain
-May result from strain of paraspinal muscles, ligamentous injury, irritation of facet joints (excludes anatomic causes, e.g. herniated disk, tumor)
-Neurogenic Claudication
-“Pseudoclaudication”
-Symptom of Lumbar stenosis causing impingement or inflammation on the nerves
-Symptoms proximal to distal (vascular is distal to proximal)
-Walking & standing causes fatigue & weakness is not relieved with sitting (vascular is relieved with sitting)
neck and arm pain
-paravertebral discomfort relieved with rest and aggravated by activity -> acute neck sprain
-young pt with abnormal upper extremity neuro exam -> cervical radiculopathy due to herniated nucleus pulposus
-older pt with limited ROM and pain on extension -> cervical radiculopathy due to cervical spondylosis
-urinary dysfunction with global sensory changes, weakness, and abnormal gait -> cervical myelopathy secondary to cervical spondylosis or trauma
-shoulder pain and positive impingement -> shoulder pathology
-tinel sign and non-dermatomal distribution of sx -> peripheral nerve entrapment
cervical radiculopathy
-Herniated Cervical Disk
-Referred neurogenic pain in the distribution or a nerve root, with or without numbness, weakness, or loss of reflexes
-<40 MC -> herniated disk
-Older pts -> MC foraminal narrowing from degenerative disk & arthritic facet joint
-Sx: neck pain, radicular pain, numbness, muscle spasms, decreased grip strength, loss of coordination
-P/E: Loss of cervical lordosis, decreased ROM, + Spurling test.
-Look for changes throughout C4-C7 neuro exam (Pain, Sensory change, Motor weakness atrophy, Reflex change)
-Dx tests: X-Ray, MRI or CT confirms dx (not necessary routinely), Electromyography (EMG) - reserved for preop planning
-Differential: Adhesive capsulitis, MI, Peripheral nerve entrapment, RTC disease, Thoracic Outlet Syndrome
Tx: - Resolution of sx usually within 6-12 wks
-NSAID’s, oral steroids, phys therapy
-Referrals/Red Flags: Failure of conservative tx, atrophy, motor weakness, signs of myelopathy, infection, tumor
cervical spondylosis
-Degenerative disk ds or cervical ARTHRITIS
-Bone spurs, buckling of the ligamentum flavum, herniated disk -> All result in narrowing of neural foramen and possible stenosis of canal
-Sx: Stiffness & neck pain worse upright. Muscle spasm, pain with ROM
-P/E: Lateral tenderness, spinous process tenderness, Decreased ROM,
-Look for changes throughout C4-C7 neuro exam (Pain, Sensory change, Motor weakness atrophy, Reflex change)
-Dx Tests: X-rays (degenerative changes MC @ C5-6 & C6-7)
-Diff dx: Mets (night pain), HD, Tumor, Vertebral subluxation (RA, trauma)
-Tx: NSAID’s, Supportive (cervical pillow, sleep on side) P.T.
-Surgical decompression (laminectomy) - indicated with intractable pain, progressive neurologic findings, cervical myelopathy, spinal cord compression
-Referrals/Red Flags: Same as reasons for surgery
cervical fracture
-result of high energy trauma
-Sx: Severe pain, spasm, point tenderness
-Global sensory or motor deficits suggest spinal cord injury
-P/E: Palpate for tenderness and spasm.
-Feel for any gaps or step-off
-Check sensory of dermatomes and motor function -> Perianal sensation, sphincter tone & bulbocavernosus reflex should be assessed
-Bulbocavernosus reflex = stimulate glans penis or clitoris and monitor anal tone -> Often monitored via emg.
-Dx Tests: AP, Lateral, Odontoid
-Injuries @ upper & lower portions of C-Spine most often missed.
-AP- malalignment of spinous processes
-Lateral- anterior soft-tissue swelling, vertebral height, alignment of vertebral bodies, facet joints, & spinous processes
Odontoid- subtle fracture, C1 lateral mass widening, occipital condyle position
-Swimmers View - visualizes cervicothoracic junction
-Carefully evaluate radiographs
-Signs of instability (dont memorize #s)
->3.5 mm translation of a vertebral body
->11 degrees of angulation of adjacent vertebral bodies
-!! acute situation CT scan is obtained
-Tx: Immobilization and/or surgical management if indicated
-high suspicion for injury in pts intoxicated, uncooperative, or unconscious
fracture of thoracic and lumbar spine
-high-energy trauma
-Can occur with minimal trauma in those with osteoporosis, tumors, infection, chronic steroid use
-Sx: Moderate to severe back pain. Worse with motion.
-P/E: Step-off or gap between spinous processes with swelling & hematoma are classic in an unstable flexion-distraction or burst fracture
-Neuro exam, Perianal sensation, sphincter tone & bulbocavernosus reflex should be assessed
-Types:
-Simple Compression Fracture - involve only the anterior half of the vertebral body are stable
-Burst Fracture - compression fracture that extends to the posterior third of vertebral body
-Flexion-distraction - disrupts anterior & posterior bone & ligamentous structures. Highly Unstable!
fracture of thoracic and lumbar spine dx and tx
-Dx. Tests: AP & Lateral X-rays
-AP: Look for transverse fractures or widening of the interpedicular distance (unstable burst)
-Lateral: Loss of height of the anterior wall and resultant kyphotic deformity. Widening of the space between adjacent spinous processes
-!!In acute situation CT scan is obtained
-Tx: Goals
-1) Prevent neurologic damage
-2) Restore stability
-3) Restore Normal function
-Hyperextension bracing, Pain management, phys. Therapy, encouragement,
-Surgical intervention
kyphoplasty/vertebroplasty
Kyphoplasty = cement is injected into a balloon
Vertebroplasty = cement injected into vertebra
lumbar herniated disk
-Sciatica / Lumbar radiculopathy
-Pain from direct compression of the nerve root & in part from chemical irritation of the nerve root by substances in the nucleus pulposus
-Affects 2% of the population
-10- 20% of those pts have sx lasting longer than 6 wks
-Sx: Unilateral radicular leg pain with LBP
-Pain worse with sitting
-Lying relieves pain
-P/E: Inspect for list to one side
+ SLR test or contralateral SLR test
-Classic findings:
-L3-4 disk (5%): Ant tib weakness, numbness in shin, asymmetric knee reflex
-L4-5 disk (67%): EHL weakness, numbness top of foot & 1st webspace
-L5-S1 disk (28%): Weakness with plantar flexion (gastrocsoleus, numbness lateral foot, asymmetric ankle reflex
-Dx. Tests: -X-rays: show degenerative changes
-MRI for dx or pre-op planning
-Differential: Cauda equina syndrome, Extraspinal nerve entrapment, Hip or knee arthritis, Spinal stenosis, Trochanteric bursitis, Vascular insufficiency
Tx:
-1-2 days bed rest for acute episode
-NSAID’s, APAP, Muscle relaxers, Oral steroids, epidural injections, Phys. therapy
-Referral/Red flags: Cauda equina syndrome, urinary retention, perianal numbness, motor loss, severe single nerve root paralysis, progressive neurologic deficit, radicular symptoms >6wks
lumbar spinal stenosis
-Neurogenic claudication
-Narrowing of the lumbar spinal canal & subsequent compression of the nerve roots
-30% of the population >60 y.o.
-L4-5, L3-4, L1-2 MC
-Severe stenosis before symptoms occur
-Sx: Neurogenic claudication with radicular complaints
-Proximal → Distal
-Pain with walking that does not subside when walking stops
-Pain with extension (narrows the canal)
-P/E: - Muscle weakness in legs
-Can have sensory changes
-Can have diminished reflexes
-Dx. Tests: X-rays: AP & Lateral
-May show intervertebral disk narrowing, spondylolisthesis, osteopenia
-MRI to confirm
-Differential: AAA, Arterial insufficiency, DM, Infection, Tumor
-Tx: - * Prevent progression.
-Physical therapy, Abdominal muscle strength, weight loss, lumbar flexion exercises, NSAID’s
-50% relief with injections
-Referral/Red flags: Neurologic deficit, gait disturbance, bowel or bladder dysfunction, night pain (indicates advanced disease)
spondylolisthesis: degenerative
-Forward slippage of a lumbar vertebral body
-Caused by degeneration & alterations in facet joints along with degeneration of intervertebral disk
-The lamina and pars interarticularis are intact
-M.C. 4th & 5th vertebral bodies
-Woman >40 y.o.
-Sx: Back pain aggravated with activities
-P/E:
-Note gaps or step-off
-Evaluate motor, sensory function & reflexes (diminished knee & ankle reflexes)
-Dx. Tests: X-rays: AP & Lateral
-Lateral shows slippage of one vertebra onto another
-Degenerative changes and vertebral space narrowing
-Differential: Iatrogenic instability (diskectomy or decompression), pathologic fracture, trauma, spondylolisthesis (pars defect)
-Tx: Flexion exercises, stretching, corset, NSAID’s.
-Lifestyle changes
-MRI & consideration of surgical stabilization
-Referral/Red Flags: Neurogenic claudication symptoms, cauda equina syndrome
spondylolisthesis: isthmic
-Forward slippage of a lumbar vertebral body
-In children between L5 & S1
-!Defect! at junction of lamina with the pedicle (pars interarticularis), leaving the posterior element without a bony connection
-“Fatigue Fracture”
-Defect only = Spondyloysis
-Gymnasts/Football players
-Sx: - Asymptomatic/minimal sx/back pain with posterior radiation
-Hamstring spasms & limited hamstring flexibility
-P/E: - Palpate for step-off
-Diminished lordosis
-Neurologic deficits are rare
-Dx.Tests: - X-Rays- AP/lateral/oblique. Absent neck in the “Scotty Dog”(pars interarticularis defect)
-Differential: Intervertebral disk injury
-Tx: Strengthening with P.T.
-Periodic (6mo) radiographs until growth is complete
-Modification of activities
-Thoracolumbosacral orthosis for pain relief
-Surgical fusion for progressive slippage
-referral/red flags -> progressive slippage and significant pain
cauda equina syndrome
-conus medullaris (distal spinal cord) terminates at L1-2.
-Spinal canal is filled with L2-S4 nerve roots= Cauda Equina
-sudden reduction in the volume of the lumbar spinal canal causes compression and paralysis of roots distal to the conus
-Prevalence is low: 1-2% of patients who undergo surgery for HD. .0004 in all patients with LBP
-Causes:
-HD
-Epidural abscess
-Epidural hematoma
-Fracture
-Sx: - Radicular pain and numbness in legs
-Pain decreases as paralysis progresses
-Difficulty voiding or loss of urinary and anal sphincter control
-Urinary retention is most consistent feature (90% sensitive)
-Saddle anesthesia
-3 Classic Patterns
-Group 1: Sudden onset with no previous symptoms
-Group 2: Previous low back pain and/or unilateral radicular symptoms that results in cauda equina syndrome
-Group 3: Low back pain and bilateral radicular symptoms that evolve into cauda equina syndrome
spinal orthotics: soft cervical collar (dont need to know orthotics)
-Short-term use in cervical sprains or intermittent use with cervical spondylolysis
-Position the neck in approx. 10 degrees of flexion
-Maintain isometric exercises with its use
spinal orthotics: philadelphia collar
-Provides better control of rotation
-Used for acute sprains or suspected fractures
spinal orthotics: rigid cervical orthotic
-Miami J orthosis
-Hard cervical collar that limits flexion & extension
-Has a rigid plastic component that extends to chest
spinal orthotics: halo brace
-Provides superior immobilization to the C-spine
-Virtually no cervical spinal motion occurs
spinal orthotics: thoracolumbosacral corset
Provides support for patients with osteoporosis or acute thoracic sprains
spinal orthotics: jewett three point orthosis
-Three-point fixation over sternum and pubis anteriorly and mid-spine posteriorly
-Limit flexion/extension. Allows limited rotation
-Used for thoracic sprains and simple compression fractures
spinal orthotics: total contact thoracolumbar orthosis
-Prefabricated modules or made from a plastic mold based on patient’s measurements
-Used as definitive treatment in patients with stable burst fractures of the thoracolumbar spine or as post-op aid after spinal fusion
spinal orthotics: elastic belts
May provide some lumbar and abdominal support with mild strains
spinal orthotics: lumbosacral corset
-Limit motion and are useful for a lumbar strain or acute HD
-Limit its use and provide back strengthening once its use is completed
cervical facet injection
-Can be used to dx or treat
-Local anesthetic & corticosteroid
-Done under fluoroscopy
interlaminar epidural injection
-Into the epidural space (surrounding the dura)
-Herniated Disk / Degenerative changes
-Local anesthetic & corticosteroid
-Done under fluoroscopy
lumbar caudal epidural injection
-Into the epidural space (surrounding the dura)
-Herniated Disk / Degenerative changes
-Often used when patient has hardware in place
-Local anesthetic & corticosteroid
-Done under fluoroscopy
surgical tx: disk replacement
-Preserve motion thus preventing adjacent level breakdown and allowing for more normal biomechanics
-Long-term data not available
-Technically difficult operation
