Spine Flashcards
Sudden nonradicular neck + shoulder pain, pain anywhere from occiput to cervical-thoracic junction
Worse with motion, may have spasm of trapezius pain
Headache
Can last for months
acute cervical sprain
“Whiplash” – trauma of hyperextension → hyperflexion causing ligamentous and flexion/extension injury
acute cervical sprain
PE: tenderness, LROM, NORMAL neurovascular exam of neck
XR: AP/lat/odontoid/flexion/extension, rule out fracture instability, loss of cervical lordosis
acute cervical sprain
How do you treat an acute cervical sprain
1-2 weeks in a soft collar with short course pain meds, NSAIDs, muscle relaxants, heat/ice, physical therapy, massage
Can take up to 6-12 months to resolve
Point tenderness, pain with motion, guarding, radiculopathy, gait disturbance, weakness, loss of bowel/bladder control
cervical fracture
Posterior cortex involvement with retropulsion into canal (cervical)
burst fracture
C7 spinous process fracture
clay shoveler’s fracture
Consider high risk of neurological involvement with
facet subluxation or dislocation
C2 traumatic fracture
hangman’s fracture
C1 burst fracture with axial loading injury (dive into shallow water)
jefferson’s fracture
there’s 3 different types of this cervical fracture of the C2
odontoid fracture
High energy trauma - often can cause other trauma – intoxication, closed head trauma, unconscious
cervical fracture
Keep immobilized until clear with x-rays and exam
PE: “step off”, +/- ecchymosis, swelling
→ include rectal exam to evaluate sphincter function
XR: AP/lat/odontoid/swimmer’s
CT scan
~ need flex/ext views at follow up appointment for patient who is alert/cleared
cervical fracture
Unilateral arm pain with numbness, tingling, paresthesias, weakness, loss of coordination, diminished grip strength
Loss of fine motor skills, bowel or bladder functions
Ass with headaches, neck and shoulder pain
cervical radiculopathy
Referred neurogenic pain in distribution of a cervical nerve root
Young = acute HNP
Elderly = foraminal narrowing from DDD or arthritis
cervical radiculopathy
Imaging: AP/lat, MRI CT myelogram, EMG/NCV can help with ruling out and finding final diagnosis of –
cervical radiculopathy
This is a reminder
to review different radiculopathies compared to their C spine level
C5 radiculopathy radiates to
medial shoulder blade and upper lateral arm from neck
C6 radiculopathy radiates to
thumb and pointer finger all the way from neck (laterally) and medial shoulder blade
C7 radiculopathy radiates to
middle finger down arm from neck and medial shoulder blade
C8 radiculopathy radiates
from entirety of medial shoulder blade down posterior arm to middle and pinky fingers and potentially anterior other arm
How do you treat cervical radiculopathy
NSAIDs, PT
Neuro deficit needs a referral to specialist
Generally bilateral – chronic neck pain worse when upright with popping, grinding
Headache
cervical degenerative disc disease
“Arthritis, spondylosis” with ingrowth of bone spurs, ligament hypertrophy,c chronic herniations/bulges, with disc collapse
cervical degenerative disc disease
XR: osteophytes, subluxation/listhesis
Neuro symptoms = MRI or CT of cervical spine
cervical degenerative disc disease
How do you treat cervical degenerative disc disease?
NSAIDS, PT, surgery
Radiation to buttocks with a change in position frequently, exaggerated behavior, poor fitness
Muscle spasms that are activity-related, non-radiating to legs, not associated with neurological symptoms
low back strain
What are RFs for low back strain?
Smoking
Personality disorders
Low pay
Acute low back pain, lumbar strain, mechanical back pain, often from repeated twisting or lifting
low back strain
PE: diffuse tenderness in low back/SI region with normal reflexes and strength, with ROM = pain
XR: AP/lat to rule out other causes
low back strain
How do you treat a low back strain
Avoid physical activity with NSAIDS/tylenol, avoid narcotics, muscle relaxers, steroids
PT
No improvement after 4 weeks = referral to specialist
Recurrent and episodic –
Back pain with radiation into one or both buttocks, with mechanical or axial movements +/- intermittent sciatica that interferes with work and mood disturbances, commonly in depression
degenerative disc disease
Chronic low back pain w/ symptoms >3 months from weight, trauma, infection, hereditary, or tobacco use
degenerative disc disease
PE: pain with palpation, negative SLR, exaggerated behavior
XR: AP/lat = disc space collapse, osteophytes, “vacuum sign”
degenerative disc disease
How do you treat a degenerative disc disease?
NSAIDs, avoid narcotics with antidepressants, PT, weight loss, tobacco cessation
Return to activity, refer to pain management
Unilateral abrupt and associated with back pain radiating down to leg, worse with sitting, coughing, or sneezing
Relief = lying on back with pillows under knees or fetal position
Leaning towards one side
lumbar radiculopathy
“Sciatica” with nerve dysfunction of the leg from HNP, stenosis, arthritis
lumbar radiculopathy
PE: seated SLR
– flip sign
– contralateral side could be +
Always check reflexes, strength, and sensation
XR: AP/lat, MRI
lumbar radiculopathy
nerve root L4 radiates to
back of butt down anteriorly of leg with numbness above patella and a bit above
nerve root L5 radiates
from sacrum down more lateral leg to lateral calf
nerve root S1 radiates
entirely posterior down back of calf and bottom of foot
How do you treat lumbar radiculopathy?
NSAIDs, steroids/ESI up to 3 in 6-12 month period, pain meds, rest/PT, surgery
Poor walking tolerance due to leg pain, numbness, paresthesia – weakness with walking and standing, “my legs don’t work right”
→ sit down to find relief
→ worse with extension (standing, walking, lying)
→ bending over shopping cart/ leaning forward
Proximal to distal
NOT like vascular claudication – no absent pulses, or skin changes
spinal stenosis
Congenital or acquired narrowing of spinal canal with compression of nerve roots
“Neurogenic claudication”
MCC: degenerative arthritis or spondylolysis esp >60
spinal stenosis
PE: diminished reflexes, weakness
Ask about bowel/bladder function, check sphincter tone
XR: degenerative changes, instability
EMG, MRI/CT myelogram
spinal stenosis
How do you treat spinal stenosis?
NSAIDs, steroid dose pack/ESI, PT/water therapy
Surgery
Stenosis symptoms = weakness, neurogenic claudication
Radiculopathy = leg pain
HNP, mechanical back pain
MC = lower back pain, may have bowel or bladder dysfunction
degenerative spondylolisthesis
What are RFs for degenerative spondylolisthesis?
Post trauma
Pars deficit
Previous surgery on spine
Spondylolysis (gymnast, weight lifter, football player)
“Spondy” – slippage of one vertebral body in relation to the one below, with “Stair stepping”
– anterior slip = canal narrowing
– posterior slip = neuroforaminal narrowing
Pars + lamina intact but facet joints + disc abnormal
degenerative spondylolisthesis
PE: diminished reflexes, weakness, + SLR
XR: slipping of vertebrae
AP/lat - consider flexion + extension, MRI
degenerative spondylolisthesis
How do you treat degenerative spondylolisthesis?
Activity modification, NSAIDs, bracing/orthoses, surgery
LBP with acute spasms, pain radiating posteriorly to below the knees
Acute or chronic
Slippage vs. non-slippage and only fracture
adolescent spondylolisthesis/spondylolysis
Gymnast, weight lifter, football players commonly have
adolescent spondylolisthesis/spondylolysis
“Pars defect” in between L5 and S1 with defect in pars articularis, fatigue fracture
adolescent spondylolisthesis/spondylolysis
PE: diminished lordosis, flattening of the buttocks
SLR
Tight hamstrings
Neuro exam = normal
XR: AP/lat/oblique with “Scotty dog collar”
flex/extension = spondylolisthesis
SPECT imaging to see if active defect
MRI = edema in paris
adolescent spondylolisthesis/spondylolysis
How do you treat adolescent spondylolisthesis/spondylolysis?
Rigid bracing/rest
Refractory = surgery
Sudden onset paralysis L2-S4 downward
(S2-S4 control bladder and bowel function)
Back pain and numbness bilaterally with perineal numbness in saddle
Significant weakness, urinary retention or loss of control, radiation of pain bilaterally
cauda equina syndrome
Compression of cauda equina → paralysis from L2-S4 and downward from large HNP, epidural hematoma, abscess, trauma
MCC: massive lumbar disc herniation
cauda equina syndrome
PE: Unable to get out of chair, loss of anal sphincter tone, motor sensory exam
XR: MRI/CT myelogram
AP/lat, lab work to rule out others
cauda equina syndrome
cauda equina syndrome is a – —-
surgical emergency
metastatic disease’s MC symptom is
pain
metstatic disease is often an
incidental finding
XR:
first sign = lost of integrity of pedicle
– “winking owl” sign
Fractures = loss of bone
metastatic disease
LBP, radiculopathy due to asymmetric collapse, “hump”, commonly with childhood onset
Abnormalities of coronal, axial, sagittal planes
Can be degenerative from osteoporosis, spondylolisthesis, DDD
scoliosis
XR: AP/lat
– measure Cobb angle (>/= 10 degrees)
Adams forward bend test = + asymmetry
scoliosis
scoliosis tx
NSAIDs, PT, surgery
Bracing
Rounded upper back
May have pain
Elderly, Scheuermann’s disease
kyphosis
