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Orthopedics > Spine > Flashcards

Spine Flashcards

1
Q

Cervical nerve root relationt o vertebrae

A

• 7 cervical vertebrae; 8 cervical nerve roots

nerve root exits above vertebra (i.e. C4 nerve root exits above C4 vertebra), C8 nerve root exits below C7 vertebra

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2
Q

Radiculopathy definition

A

impinegement of nerve root

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3
Q

Myelopathy deifnition

A

impingement of spinal cord

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4
Q

Cervical spine special testing

A
  • compression test: pressure on head worsens radicular pain
  • distraction test: traction on head relieves radicular symptoms
  • Valsalva test: Valsalva maneuver increases intrathecal pressure and causes radicular pain
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5
Q

C5 motor, sensory and reflex

A

Motor - Deltoid
Biceps
Wrist extension

Sensory -
Axillary nerve

Reflex - biceps

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6
Q

C6 motor, sensory and reflex

A

Motor -
biceps
brachioradialis

Sensory -
thumb

Reflex -
biceps
brachioradialis

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7
Q

C7 motor, sensory and reflex

A

Motor -
triceps
wrist flexion
finger extension

sensory -
index and middle finger

reflex -
triceps

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8
Q

C8 motor, sensory and reflex

A

motor -
interossei
digital flexors

sensory -
ring and little finger

reflex -
finger jerk

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9
Q

Appropriate cervical neck anterior soft tissue space

A

C3 0-3 mm

C4 0-10 mm

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10
Q

DDx of C-spine pain

A

neck muscle strain, cervical spondylosis, cervical stenosis, RA (spondylitis), traumatic injury, whiplash, myofascial pain syndrome

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11
Q

Where does the spinal cord terminate

A

Conus medullaris (L1/2)

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12
Q

Relation of nerve roots to vertebra in the thoracolumbar spine

A

individual nerve roots exit below pedicle of vertebra (i.e. L4 nerve root exits below L4 pedicle)

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13
Q

Thoracolumbar spine special tests

A

• straight leg raise: passive lifting of leg (30-70°) reproduces radicular symptoms of pain radiating down posterior/lateral leg to knee ± into foot

Lasegue maneuver: dorsiflexion of foot during straight leg raise makes symptoms worse or if leg is less elevated, dorsiflexion will bring on symptoms

• femoral stretch test: with patient prone, flexing the knee of the affected side and passively extending the hip results in radicular symptoms of unilateral pain in anterior thigh

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14
Q

Lumbar radiculopathy/neuropathy motor/sensory, screening test, reflex, test for L4

A

Motor -
Quadriceps (knee extension + hip adduction)
Tibialis anterior (ankle inversion dorsiflexion)

Sensory - medial malleolus

Screening test - squat and ris

Reflex - patellar

Test - femoral stretch

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15
Q

Lumbar radiculopathy/neuropathy motor/sensory, screening test, reflex, test for L5

A 
Motor - 
Extensor hallucis longus 
Gluteus medius (hip abduction)

Sensory -
1st dorsal webspace and lateral leg

Screening test -
heel walking

Reflex - 
medial hamstring (unreliable)

Test -
straight leg raise

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16
Q

Lumbar radiculopathy/neuropathy motor/sensory, screening test, reflex, test for S1

A

Motor -
Peroneus longus + brevis (ankle eversion)
Gastroc + soleus (plantar flexion)

Sensory - lateral foot

Screening tst - walking on toes

Reflex - Achilles

Test - straight leg raise

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17
Q

Ddx of back pain

A
  1. . mechanical or nerve compression (>90%)
    ■ degenerative (disc, facet, ligament)
    ■ peripheral nerve compression (disc herniation)
    ■ spinal stenosis (congenital, osteophyte, central disc)
    ■ cauda equina syndrome
  2. others (<10%)
    ■ neoplastic (primary, metastatic, multiple myeloma)
    ■ infectious (osteomyelitis, TB)
    ■ metabolic (osteoporosis)
    ■ traumatic fracture (compression, distraction, translation, rotation)
    ■ spondyloarthropathies (ankylosing spondylitis)
    ■ referred (aorta, renal, ureter, pancreas)
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18
Q

Degenerative disc disease description

A

• loss of vertebral disc height with age resulting in
■ bulging and tears of annulus fibrosus
■ change in alignment of facet joints
■ osteophyte formation

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19
Q

Degenerative disc disease mechanism

A

compression over time with age

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20
Q

Degenerative disc disease clinical features

A
  • axial back pain without radicular symptoms
  • pain worse with axial loading and flexion
  • negative straight leg raise
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21
Q

Degenerative disc disease investigations

A

X-ray, MRI, provocative discography

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22
Q

Degenerative disc disease treatment

A

• non-operative
■ staying active with modified activity
■ back strengthening
■ NSAIDs
■ do not treat with opioids; no proven efficacy of spinal traction or manipulation

• operative – rarely indicated
■ decompression ± fusion
■ no difference in outcome between non-operative and surgical management at 2 yr

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23
Q

Spinal stenosis description

A
  • narrowing of spinal canal <10 mm
  • congenital (idiopathic, osteopetrosis, achondroplasia) or acquired (degenerative, iatrogenic – post spinal surgery, ankylosing spondylosis, Paget’s disease, trauma)
24
Q

Spinal stenosis clinical features

A
  • ± bilateral back and leg pain
  • neurogenic claudication
  • ± motor weakness
  • normal back flexion; difficulty with back extension (Kemp sign)
  • positive straight leg raise, pain not worse with Valsalva
25
Q

Spinal stenosis investigations

A

CT/MRI reveals narrowing of spinal canal but gold standard = CT myelogram

26
Q

Spinal stenosis treatment

A

• non-operative
■ vigorous physiotherapy (flexion exercises, stretch/strength exercises), NSAIDs, lumbar epidural steroids

• operative
■ indication: non-operative failure >6 mo
■ decompressive surgery

27
Q

Differentiating claudication

A
  1. Aggravation
    Neurogenic - with standing or exercise, walking distance variable
    Vascular - walking set distance
  2. Alleviation
    Neurogenic - change in position (usually flexion, sitting, lying down)
    Vascular - stop walking
  3. Time -
    Neurogenic - Relief in ~10 mins
    Vascular - Relief in ~2 mins
  4. Character
    Neurogenic - Neurogenic +/- neurological deficit
    Vascular - muscular cramping

NEUROGENIC CLAUDICATION IS POSITION DEPENDENT

VASCULAR CLAUDICATION IS EXERCISE DEPENDENT

28
Q

What is mechanical back pain

A

back pain NOT due to prolapsed disc or any other clearly defined pathology

29
Q

mechanical back pain clinical features

A
  • dull backache aggravated by activity and prolonged standing
  • morning stiffness
  • no neurological signs
30
Q

mechanical back pain treatment

A
  • symptomatic (analgesics, physiotherapy)

* prognosis: symptoms may resolve in 4-6 wk, others become chronic

31
Q

Lumbar disc herniation definition and usual presentation/demographic

A
  • tear in annulus fibrosus allows protrusion of nucleus pulposus causing either a central, posterolateral, or lateral disc herniation, most commonly at L5-S1 > L4-5 > L3-4
  • 3:1 male to female
  • only 5% become symptomatic
  • usually a history of flexion-type injury
32
Q

Lumbar disc herniation clinical features

A
  • back dominant pain (central herniation) or leg dominant pain (lateral herniation)
  • tenderness between spinous processes at affected level
  • muscle spasm ± loss of normal lumbar lordosis

• neurological disturbance is segmental and varies with level of central herniation
■ motor weakness (L4, L5, S1)
■ diminished reflexes (L4, S1)
■ diminished sensation (L4, L5, S1)

  • positive straight leg raise
  • positive contralateral SLR
  • positive Lasegue and Bowstring sign
  • cauda equina syndrome (present in 1-10%): surgical emergency
33
Q

Lumbar disc herniation investigations

A

• X-ray MRI,

consider a post-void residual volume to check for urinary retention; post-void >100 mL should heighten suspicion for cauda equina syndrome

34
Q

Lumbar disc herniation treatment

A

• non-operative
■ symptomatic
◆ extension protocol
◆ NSAIDS

• operative
■ indication: progressive neurological deficit, failure of symptoms to resolve within 3 mo, or cauda equina syndrome due to central disc herniation
■ surgical discectomy

35
Q

Lumbar disc herniation prognosis

A

90% of patients improve in 3 months with non-operative treatment

36
Q

MRI abnormalities and what they mean for management of back pain

A

MRI abnormalities (e.g. spinal stenosis, disc herniation) are quite common in both asymptomatic and symptomatic individuals and are not necessarily an indication for intervention without clinical correlation

37
Q

Red flags for BACK PAIN

A 
BACK PAIN 
Bowel or bladder dysfunction 
Anesthesia (saddle) 
Constitutional symptoms/malignancy 
Khronic disease 
Paresthesias 
Age >50 yr 
IV drug use 
Neuromotor deficits
38
Q

Types of low back pain

A

Mechanical back pain

  • disc origin
  • facet origin

Direct nerve root compression

  • spinal stenosis
  • root compression
39
Q

Mechanical back pain disc origin pain dominance, aggravation, onset, duration, treatment

A

Back

Flexion

Gradual

Long (weeks, months)

Relief of strain, exercise

40
Q

Mechanical back pain facet origin pain dominance, aggravation, onset, duration, treatment

A

Back

Extension, standing, walking

More sudden

Shorter (days, weeks)

Relief of strain, exercise

41
Q

Direct nerve root compression spinal stenosis pain dominance, aggravation, onset, duration, treatment

A

Leg

Exercise, extension, walking, standing

Congenital or acquired

Acute or chronic history (weeks to months)

Relief of strain, exercise + surgical decompression if progressive or severe deficit

42
Q

Direct nerve root compression root compression pain dominance, aggravation, onset, duration, treatment

A

Leg

Flexion

Acute leg +/- back pain

Short episode attacks (minutes)

Relief of strain, exercise + surgical decompression if progressive or severe deficit

43
Q

Approach to back pain etiology

A

Back dominant

a) Constant - then inflammatory or mechanical
b) Intermittent - then disc herniation (central) or facet joint

Leg dominant

a) constant - then disc herniation (lateral)
b) intermittent - spinal stenosis

44
Q

Sciatica description and most common cause

A

Most common symptom of radiculopathy (L4-S3)

  • Leg dominant, constant, burning pain
  • Pain radiates down leg ± foot
  • Most common cause = disc herniation
45
Q

Spondylolysis definition

A

defect in the pars interarticularis with no movement of the vertebral bodies

46
Q

Spondylolysis mechanism

A

• trauma: gymnasts, weightlifters, backpackers, loggers, labourers

47
Q

Spondylolysis clinical features

A

• activity-related back pain, pain with unilateral extension (Michelis’ test)

48
Q

Spondylolysis investigations

A
  • oblique X-ray: “collar” break in the “Scottie dog’s” neck
  • bone scan
  • CT scan
49
Q

Spondylolysis treatment

A

• non-operative

■ activity restriction, brace, stretching exercise

50
Q

ADULT ISTHMIC SPONDYLOLISTHESIS

definition

A

defect in pars interarticularis causing a forward translation or slippage of one vertebra on another, usually at L5-S1, less commonly at L4-5

51
Q

ADULT ISTHMIC SPONDYLOLISTHESIS

mechanism

A

• congenital (children), degenerative (adults), traumatic pathological, teratogenic

52
Q

ADULT ISTHMIC SPONDYLOLISTHESIS

clinical features

A
  • lower back pain radiating to buttocks relieved with sitting
  • neurogenic claudication
  • L5 radiculopathy
  • Meyerding Classification (percentage of slip
53
Q

ADULT ISTHMIC SPONDYLOLISTHESIS

investigations

A

• X-ray (AP, lateral, oblique flexion-extension views), MRI

54
Q

ADULT ISTHMIC SPONDYLOLISTHESIS

treatment

A
  • non-operative ■ activity restriction, bracing, NSAIDS

* operative

55
Q

ADULT ISTHMIC SPONDYLOLISTHESIS

classification and treatment

A

Class 1
0-25% slip
Symptomatic operative fusion only for intractable pain

Class 2
25-50%
Same as above

Class 3
50-75% slip
Decompression for spondylolisthesis and spinal fusion

Class 4
75-100%
Same as above

Class 5
>100%
Same as above

56
Q

ADULT ISTHMIC SPONDYLOLISTHESIS Specific complications

A

may present as cauda equina syndrome due to roots being stretched over the edge of L5 or sacrum

Orthopedics (19 decks)

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