Spine and Neck Flashcards
Quick: Anatomat review of the spine
Cervical = 7 cervical vertebrae
- C1-C7
- C1 = atlas; holds head vat occipital codyles
- C2 = axis ; lets head swivle, hads the Dens: which allows the swivle
- contain transverse foramen for the vertebral arteries to pass
Thoracic = 12 vertebrae
- contain articulations for the ribs
- the spinous processes point more inferiorly
Lumbar = 5 vertebrae
- wide to hold all the weight
Spinal Cord: runs through the middle: terminates at T12/L1 and L2/L3
L1/L2 = conus and to the cauda equina
- 8 cervcial nerve roots because C1 exits above C1
- ALL and PLL hold the cord in place
- ligamentum flavum sits behind the cord
terminology
spondylosis: degenerative/osteoarthritic changes in the spinal anatomy over time
- can be disc spance narrowing
- can result in canal stenosis
- see back pain/stiffness and limited movement
spondylolyisis: a stress fracture through the pars: the region of a vertebrae which holds the superior and inferior facet articault processes of a verabrea: a fracture here
- pain pain worse with extension
- stress fracture: repeated jumping, labor, etc.
- scotty dog collar
Spondylolithesis: a slippage of the vertebrae onto another
can be anterior, posterio or lateral slippage
- commonly in the lumbar spine
- pars fracture, arthritis, abnormal cartialge can cause this slip
Spinal Stenosis: narrowing of the spinal canal which puts pressure on the nerve roots as they exit
- can be due to disc herniation, ligamentum flavum hypertrophy (forward movement), slippage
- injury or fracture can cause ths
- tumor or spinal lesions
- congenital narrowing too
Neck Pain
Etiologies of the pain
Structural
- cervical spondylosis
- osteoarthritis
- herniated disc
- spinal cord tumor
- infection (osteomyleitis, diskitis, abscess)
- RA
- fibromyalgia
- muscle strains, whiplash, tension HA, shoulder issues (C5!!)
Axial v Radicualr Neck Pain
how to tell them apart
Axial: MSK issue
- pain and stiffness that will NOT radiate away from the neck
- dull, deep and episodic pain
- worse in the AM or with activity
- relieved by rest
- could have no specifi injury history, could be repetitiv euse
radicular Neck pain
- gradual or abrupt onset of shock like sensation to the shoulders or other areas
- can radiate the paint down the arm to wrist/hand
- sharp, stabbing or burning pain
- motor and sensory symptoms (myotomes/dermatomes)
- symptoms worse with hyperextension toward the side (cuases nerve root compression)
Red Flags of Acute Neck Pain
- worse at night
- fever weight lss
- history of cancer
- hisotry of chronic infection or trauma
- changes in bowel/bladder: urinary incontinence is a cervical neck problem
- older or younger
- IV drugs
- immunocomp.
- rapid neuro issues
Myotomes
C3-T1
scoring
Dermatomes for C1-T1
C1-2-3 = neck flexion/extensions and lateral motions
C4: sholder elevation, scapular stabilizing
C5: deltoid, biceps for elbow flexion & abduct shoulder
C6: elbow flexion (thumb up) & wrist extension
C7: triceps, forearm flexors
C8: finger flexion
T1: finger abduction
5 = normal motor scoring (1-5 where 3= is cant resist the resistance)
Dermatomes
- C3: clavical
- C4: top of shoulder
- C5: shoulder to elbow
- C6: elbow to thumb, thumb side
- C7: middle and half ring half pointer
- C8: pinky and half ring
- T1: ulnar side of arm
Deep Tendon Reflexes
hypo v hyper
Gait Specifics
Hyporeflexia: think peripheral nerve issue:
hyperreflexia: CNA lesion of upper motor neurons or cerivcal spinal cord
Sissor GaitL stiff legs so they swing out and cross
Ataxic: broad based gait due to irregular foot movements
Spurling Test: compression axially to elict pain of cerivcal nerve root
Diagnostic Studies of teh Cervical Spine for pain
MRI is gold standard: to evalute sfot tissue and spinal cord/nerve impigment
- MRI withOUT contrast usually (with and without for infection)
Xray: good to see degeneration
CT: good for looking at the bones (wont show tissues/ligaments)
CT myleogram: good for those who cant MRI
EMG: for nerve root injurys
CBC, ESR/CRP, UA can help
for new nontrauma cerivcal neck pain with no red falgs: xray is first line
for new or nontrauam cerical radiopathy pain with no red flags: MRI without contrast is first line
Cervical Radiculopathy
- etiology
- presentation
- Diagnosis
Etiology
- a “pinched nerve” from the neck
- commoonly a herniated disc, compressing the nerve leaving the cord
- most commonly C5-6, C6-7 (areas where increase ROM)
Symptoms
- radiating pain to shoulder arm or hand in a dermatomal distribution
- numbness, parasthesia or weakness in mytome
Diagnosis
- MRI without contrast of the C-spine
- in combo with history and lack of muslce issues
- can get EMG to rule out peripheral nerve issues (carpel tunnel)
Treatment
- without spinal cord invovlement (myleopathy) or weakness: conservative treatment
- PT
- NSAIDS
- muscle relaxants
- lidocain patches, steroid injections
fail conservative: surgery is considered
if single disc herniated: fixed
Cervical Myelopathy
Etiology
Symptoms
Etiology
- myelopathy: spinal cord injury
- compression or the spinal cord at the cervical level
- older adultsusually
- acute onset: whiplash or MVC with underlying degeneration
- chronic: progressive age-related degeneration (herniated disc, ligamentum falvum hypertrophy) most common
- also tumrors, abcess, infection, AV malformation, chiari malformation etc.
Symptoms
- motor function issues; since spinal cord impacted
- coordination, fine motor tasks and hand weakness & gait issues
- clumsy: dropping thing, cant open doorknobs, etc.
- broad gait and bad balance
- Urinary incontinence
- can be painless or have numbness, tingling and stifness
- can see a central cord syndroome if severe
Cervical Myleopathy
Exam findings & imaging
Treatment
- gait instability
- arm and hand weakness
- upper motor neruon : +hoffmans sign: when you pull middle finger the thumb and pointer twitch/clonus
Imaging
- MRI to see the issue: herniated discs, hypertrophy of the ligamentum, etc.
Treatment
- often a progressive disorder, surgery is needed
- goal is to prevent it from worsening but may not regain function
Central Cord Syndrome
most common spinal cord injury in adults
- cape or shawl like symptoms due to chronic changes over time to the cerical neck and then provoked by acute (hyperextension, MVa, etc.)
Sensory Loss
- loss of pain and temperature at the level of lesion
- posterior column of vibration and touch are spared
Motor Loss
- decreased strength in the UE
Mechanical Neck Disorders
Etiology
Symptoms
Diagnosis
Treatment
Etiology
- joint or muslce problem causing acute or chronic pain
- poor psoture, facet joint arthropathy, strain, stress, sports/work
Symptoms
- acute or chronic isolated neck pain/upper shoulder pain
- absence of radicualr (nerve) or myelopathic (spinal cord) pain
Management
- reassurance, PT, massage, TENS, trigger points, acupuncture
Whiplash Injury: cervical
hyperextension/hyperflexion or acceleration/decceleration injruies, pain and stiffness following accident
- can cause cental cord syndrome/meulopathy in those with underlying c spine issues
- NEXCUS criteris to determine imaging
- +/- C collar
- mucle relaxants, NSAIDS, tylenol, etc.
Neck Pain in Kids
- trauma (abuse)
- sports
- torticollis
- infections
- hematoma
- inflammatory disorder
Congenital Torticollis: postural deformity at 2-4 weeks
- lateral flexion and rotation
- treat with handling and positional changes, PT and looking opposite way
Acquired torticollis : injury or inflammation of SCM or trap. due t
- trauma, acute viral or bacterial illness: strep throat, RPA or displacement of atalto-occpical joing
Etiologies for low back pain
Structural
- scoliosis
- lubar degenerative disc disease
- herniated disce
- spinal stenosis
- spondylosis
- spondilyoisthesis
Infection
cancer Tumor
OP/pagets
autoimmune
si joint dysfunction
viseral pain
red flags same as neck pain: but will have urinary retention becuase of compression of the parasympatheic nerves
Tests PE for Low Back Pain
dermatomes
myotomes
Myotomes
L2: illopsoas
L3: quads
L4: tibias anterior
L5: posterior tibialials
S1: gastrucne.
Dermatomes
L2: anterior thigh
L3: does not go below the knee
L4: to medial mall.
L5: to dorsum of foot
S1: to lateral mal. and sole of foot along the back
hyporeflex: peripheral never /root issue
hyperfrlexi: spinal cord iissue
babinski sign
stright leg raise: pain at 30-60 = siatica
FABER for SI joint or hip issues
Heel walking = lok for weak anterior tibialis
toe walking: look for weak posterior tib.
steppage (abnormal) : foot drop so they have to lift higher
Assessing Foot drop
perioneal nerve palsy v L5 pathology
L5 pathology: pain (may be higher than posterior leg)
- lost inversion
peroneal nerve palsy: pain starts below the knee
- lost eversion
Diagnosis (Imaging) of choice for low back pain
MRI: is gold standard without contrast: to see soft tissue and spinal cord too
X-rayL typically done first to see degenerative chagnes or instability
if pt has acute low back pain with or without radiculopathy, and no red flags: NO IMAGING NEEDED
if pt have subacute, chronic low back pain with or without radiculopathy, progressive sumpyomts with medical management = MRI without contrast is done
Lumbar Radiculopathy
- etiology
- symptoms
- diagnosis
Etiology
- acute, chronic and recurrent low back pain/leg pain due to nerve root compression in th elumbar spine due to a LATERALLy herniated nucleus pulposus (disc)
- commonly: L4-5, L5-S1 aka Siatica
- herniation more common in lumbar than thoracic, but still possible
- herniated disc: impact the nerve root and the decending nerve too
Symptoms
- pain; worsened with flexion and typically unilateral
- posteriolateral leg pain is upper leg and down the leg pattern (leg pain worse than back pain)
- can have numbeness and parathestias too
Lumbar Radiculopathy
(imaing only if its not acute!!!) otherwise use signs and history to help dx.
Diagnosis
- those with higher BMI and smoking at increased risk
- will have + stright leg and antalgic (weight bearing to the nonaffected side) gait & faber
Treatment
- conservative vv surgical managemetn of the disc depends on the size and severity of symptoms
- ** > 50% can resolve within 6 weeks without intervention or with conservative treating**
Conservative
- PT
- massage, ice
- NSAIDS, tylenol, muscle relaxers, etc.
pregressive pain, weakness or failing conservative treatment: surgery of microdiscectomy
Lumbar Stenosis
Etiology
Etiology
- narrowing of the lumbar spinal canal: typically due to degenerative spondylosis
- can be disc protrusion, cartialge enlargement or other
- older = increased risk
Symptoms
- gradual progression
- back and lower leg pain, weakness & gait dysfunction (bilaterally)
- sensory changes (numb and tingling)
- pain worse with standing/walking and backwards extension
- pain improved with leaning forward: shopping cart sign
- in severe: cauda equina syndrome
Lumbar Stenosis
diagnosis
Treatment
Diagnosis
PE
- nuerogenic claudication (leg pain): local and level of pain depends on what level is inovlved
- entire leg: upper Lumbar
- below knee: L4 and down
- leg weakenss, numberss, pain with flexion
- determine if the claudiacion is vascualr or neurogenic
Management
- if no motor deficits, urinar bladder retention = concervative
conservative
- NSAIDS, PT flexiona nd core work
if no relief with conservative or presents with motor weaknes, gait deficts and bowel issues
- surgical decompression
- fusion depends on degress of stenosis, etc.
Cauda Equina Syndrome
etiology
symptoms
spinal emergency
Etiology
- symptoms which result from spinal nerve compression of the cauda equina in the LS region
- mainly due to a herniated disc in lumbar region, fracture with retropulsion, spinal stenosis, tumor or hematoma/abcess
Symptoms
- low back pain and nerve leg pain bilaterally
- saddle anesthesia (numbness around inner thighs and groin, absent anal reflex, sexual dysfunction)
- inabilitiy to urinate : retention which can lead to loss of urinary control (overflow)
- LE weakness, gait issues, etc.
Cauda Equina Syndrome
Diagnosis
Treatment
Diagnosis
imediate MRI of L spine: gold standard
- bladder scan in ED and foley them asap
Treatment
- ocnsult neuro and ortho spine ASAP
- surgical decompression within 24 hours to save bowel/bladder function
Acute Spinal Cord Compression
these are emergenices to fix ASAP to save spinal cord function
Trauma
- disce hernias
- spondylosis
- fracture fragments
- subluxations
spontaneous
- sudden disc herniamtion
- abcess
- tumor
- hematoma
post-procedural compression
Treatment
- depends on mechanism
- maintain airway, monitor for neurogenic shock
- emergecny consuly for surgical decmompression
Epidural Abcess & Hematoma
Abscess
- acute neck/back pain, nerve pain, numbness, weakness, +/- cauda equina symptoms
- direct pressure on the spinal cord and nerve roots can infarct them!!!
- STAT MRI with and without contrast
- WBC with diff, culutres, ESR/CRP
- surgical emergency
Hematoma
- post-procedural, spontaneous
- weakness, numbeness, gait issue, urianry issues
- higher risk in those with anti-coags or anti-platlets
- STAT MRI with and without contrast
- surgical emergency
Vertebral Ostemyelitis
Etiology
symptoms
diagnosis
treatment
Etiology
- can be abcess, diskitis, thick tissue reaction or actual abcess
Symptoms
- back pain + Fever!!!!
- pain at night, not relieved with rest or meds
- epidural abcess: can have bowel/bladder dysfunction and neurologic issues
Diagnosis
- ESR/CRP
- WBC
- blood culutres (MRSA MSSA MC)
Treatment
- start empericabx. and tailor to culutres
- long term 6+ weeks with PICC line
- surgery: depednds if abcess is tehre
Chronic Nonspecific Back Pain
12 + weeks of nonspecific low back pain
Risk Factors
- obesity
- women
- older
- prio back pain history
- low physical activity
- other pain issues
Treatmen t
-90% will ressolve on own
councel on posture, lifting and exercise
weight loss, smoking cessaion
exercise is the mainstay of treatment
NSAIDS too
Back Pain in Pregnancy
Risk Factors
- pain in pervious pregnancy
- multiparty
- high BMI
SYmptoms
- midline above sacrum backpain
- worse pain with flexion
- SI joint pain
Treatment
- usually resolves on own because its due to mechanically carrying
- can get MRI with same reasoning as all other low back pain pts.
- erogonomic support
- masasge, exercise, PT, tylenol for pain
