Spine Beloy (Exam 2) Flashcards
What dermatome is for the shoulder pad area?
C4
Dermatome for nipple line?
T4
Dermatome for umbilicus area?
T10
Dermatome for groin/inguinal area?
L1
Dermatomes for inner thigh?
L2 L3
Dermatome for outer thigh coming over knee and anteromedial part of calves/tibia, medial part of great toe?
L4
Dermatome for lateral part of calves extending down to lateral half of great toe, including toes 2-4, the heel, and the bottom of the foot?
L5
Dermatome that runs down posteromedial part of thighs, calves?
S2
Dermatome that runs down posterolateral part of thigh/calves and pinky toe (#5)?
S1
Dermatome for lateral arm running along the radius and extending down to the thumb?
C6
Dermatome running along tricep and for fingers 2-3 (index and middle)?
C7
Dermatome running on medial side of arm down to ring and pinky fingers (4-5)?
C8
Dermatome for the anus?
S5
The spinal nerves exit the cervical spine ______ their corresponding vertebral body level, while in the thoracic and lumbar spine it is ______.
Above
Below
What cervical nerves innervate the diaphragm?
C3,4,5 keep you alive
How much CSF do we produce per day?per hour?
500mL/day
20mL/hr
Which is why it’s ok to remove 20cc/hr during surgery
Motor exam muscle grading:
What is characteristic for each 1-5/5?
5/5 full strength against resistance
4/5 diminished strength, only against minimal resistance
3/5 only able to move against gravity
2/5 able to move muscle group but not against gravity
1/5 muscle contraction but can’t move muscle
0/5 flaccid paralysis
What dermatome does each reflex test for? Brachioradialis? Biceps? Triceps? Patellar? Achilles?
Brachioradialis:C6 Biceps: C5 Triceps: C7 Patellar: L4 Achilles: S1/S2
What is a positive Hoffman’s?
Flex thumb and it clicks, could be spinal nerve compression/issue
What is a positive clonus sign and is it upper or lower motor neuron related?
Jerk the foot up and it jerks back down spastically
UMN
What is a positive Babinski and is it upper or lower motor neuron?
Toes spread (should curl) UMN
What is indicative symptoms of a herniated disc?
The nerve(s) is pinched near the spinal cord but doesn’t cause back pain, but rather a radicular pain (aka radiculopathy) in which the pain radiates down and along the dermatome correlated to that/those nerves
What common spinal degenerative condition causes most back pain? A. Disc herniation B. Facet joint osteoarthritis C. Spinal stenosis D. Degenerative disc disease E. Spondylolistesis
B. Facet joing OA
What is spinal stenosis?
Abnormal narrowing of the spinal canal that puts pressure on the spinal cord or nerves. May cause paresthesia, tingling, numbness down arms/legs, loss of bladder control or sexual dysfunction. Causes: OA, tumors, spondylolisthesis
What is spondylolisthesis?
Displacement of one vertebra compared to another (like it slipped forward)
What is ankylosing spondylosis?
a type of arthritis in which there is a long-term inflammation of the joints of the spine. Back pain is a characteristic symptom of AS, and it often comes and goes. Stiffness of the affected joints generally worsens over time. Although the cause of ankylosing spondylitis is unknown, it is believed to involve a specific human leukocyte antigen known as the HLA-B27 antigen.The underlying mechanism is believed to be autoimmune or autoinflammatory. AS is a type of seronegative spondyloarthropathy, meaning that tests show no presence of rheumatoid factor (RF) antibodies.
What is the medical term for neck pain in the cervical spine?
Cervicalgia
What test can identify where there is an interruption in the circuit of the nerve?
EMG
What kind of xray would you order on a person with cervicalgia?
4 view xray: AP/lateral/flexion/extension
What is the first line treatment for cerivcalgia?
Physical therapy: heat, massage, dry needling, stretching, strengthening
Activity modification: changing desk height level, phone/reading posture
Chiropractic care: avoid high velocity manipulations
When would you order an MRI for a pt with cervicalgia?
Instability noted on xrays if movement is >= 3mm of instability
If they have weakness 4/5 in a limb get a stat MRI
Sxs of cord compression
No improvement with conservative care after 6-8 weeks
What is myelopathy?
Severe stenosis
Digression of spinal cord prior to paralysis
Sx: gait instability, weakness, incoordination (dropping objects, can’t button shirt)
Bowel or bladder incontinence
Burning in bilat hands
What sx would you expect to see on PE for myelopathy?
Ataxic gait Hyper-reflexia Hoffman’s sign Pos babinski 2-3 beats of sustained clonus 3-4 positive DTRs (although 10-15% of the population has baseline hyperreflexia)
Can you perform thoracic spine surgery from the front?
No, lungs and heart are in the way
What kind of pathology is common of the thoracic spine?
Compression fxs
What is the third most common reason for physician visits?
Back pain
What is the cause of the majority of back pain?
Muscle strains
What is sciatica?
Radiculopathy originating around L5/S1 due to a herniated disc, spondylolisthesis, compression fx, neoplasm, or infection. Sx: pain, numbness, and tingling down posterior or lateral leg to foot and ankle, muscle weakness and loss of reflexes
What is the center of a vertebral disc called? The outer rim?
Nucleus pulposus
Anulus fibrosus
Does an annular tear require surgery?
No, strengthen muscles of back, nsaids, injections
Where do 90% of herniated discs occur?
L4/L5 or L5/S1
Lumbar stenosis is a normal progression of aging. Sometimes it can pinch the canal and cause neurogenic claudication. It does not require surgery if there are no sx. What is the classic presentation of neurogenic claudication?
Buttock and leg pain when walking
May only be able to walk a few yards before the legs get “tired:
Relieved by sitting or bending over “shopping cart sign”
What is scoliosis?
A curvature of the spine to the left or right if you’re looking at an AP view, as opposed to lordosis or kyphosis which is displacement towards the dorsal or ventral side
What is the classic sign seen on plain film for spondylolisthesis besides the vertebrae slipping forward over the vertebrae beneath it?
The “scotty dog” fx where the neck of the dog is torn and stretched
Tx for spondylolysis/spondylolisthesis?
PT, activity modification, inversion table, time, tylenol, nsaids, steroids, muscle relaxers, refer to physiatry for interventional injections
When should you order and MRI for lower back issues such as spondylolisthesis, herniated disc, neurogenic claudications, or scoliosis?
Weakness, pain with palpation of the spine, sxs of cauda equina syndrome, no improvement w/ conservative care after 6-8 weeks, lumbar instability on xrays
What are some red flags regarding lower back issues?
Leg weakness
Numbness in groin “saddle anesthesia” possible urination w/out knowing
What is cauda equina syndrome?
Urinary and/or fecal retention/incontinence
Saddle anesthesia
Leg weakness
This is a surgical emergency
What might you note on a patient with discitis/osteomyelitis?
It’s an infection Persistent fever Hx of IVDU Current or recent UTI, respiratory or other infection such as dental abscess Immunosuppressed
What is osteoporosis?
Slow loss of bone mass beginning after mid-30s
Women>men
What is a DEXA scan?
Used for pts with suspected osteoporosis Assesses lumbar vertebrae, femur, and bones in forearm Measures T-score < -1 normal -1 to 2.4 osteopenia >2.5 osteoporosis
How to manage osteoporosis?
Calcium/vit D
Bisphosphanates (inhibit osteoclast activity): fosamax, boniva, reclast
Denosumab (Prolia)(RANKL inhibitor: prevents development of osteoclasts)
Estrogen or androgen therapy
Regular exercise
The most common incomplete spinal cord injury is central cord syndrome. Describe the symptoms seen.
Effects the hands and arms. It is a major injury to the central grey matter of the spinal cord
Weakness and burning in hands
Loss of grip strength
What is Brown-Sequard syndrome?
Weakness on one side of the body
Loss of sensation on the opposite side
What is anterior cord syndrome?
Motor loss below the lesion but intact sensation
If a patient has an injury to the anterior longitudinal ligament, annulus fibrosus, and anterior 1/2 of the vertebral body, what column was injured?
Anterior
Middle
Posterior?
Anterior column
If a patient has an injury to the posterior longitudinal ligament on the posterior side of the vertebral body, the posterior annulus fibrosus of the intervertebral disck, and posterior 1/2 of the vertebral body, what column did they injure?
Anterior, middle, or posterior?
Middle column
If a patient injures their supraspinous and interspinous ligaments, or facet joint capsule, which column did they injure?
Anterior, middle, or posterior?
Posterior column
What is spinal stability based upon?
The integrity of 2 of the 3 spinal columns
Which fxs account for 50-70% of all Thoracic and Lumbar fxs?
Wedge or anterior compression fxs
What makes an anterior compression fx unstable?
Severe compression > 50% of vertebral height
Significant fx kyphosis >30deg
Rotational component to the injury
Fxs at multiple levels
Tx for anterior compression fxs?
Neurological checks May artificially raise MAP for up to 1 week Bracing (up to 3 months) Surgical stabilization Lots of PT/OT Pain mgmt including muscle relaxants
Sciatica improves within ____ months in about 75% of patients with ____?
3 months
Conservative tx
surgical options:
Decompression?
Removing part of the lamina, ligament, disc (minimally invasive)
Surgical options:
Fusions?
Able to remove joint, allows for a more robust decompression of the nerves.
Stops arthritic process as joints are no longer functioning
Surgical options:
Disc replacement?
Can be good for the right patient
Does not help with back/neck pain
Can actually make it worse if this is primary complaint
56 y/o male w/ no pmhx presents to clinic with low back pain and right posterior calf pain that started after mowing the lawn 5 days ago. Exam: he has a positive straight leg raise on the right. What nerves are most likely involved? What is at the top of your ddx? What imaging would you order? What tx would you prescribe?
L4/L5 or L5/S1
Herniated disc
Xray first, then MRI if no improvement w/ PT and nsaids
Treat by microdiscectomy (after conservative tx fails) but only provides relief for 5 years
81 y/o female presents with thoracic spine pain after falling in her garden yesterday. She states she has had a dull back pain but this is more stabbing in nature. She has also noticed some numbness along her nipple line for the last 6 months. Exam: normal, except tenderness to palp along mid thoracic spine
What is at the top of your ddx?
What imaging would you order?
What tx would you prescribe?
Vertebral fracture if pain is right over spinous process
Xray first, then MRI
Tx with APAP (don’t give nsaid-they inhibit bone formation, no narcs either)
Tx with brace or minimally invasive surgery
26 y/o female who was recently treated for a UTI present to your office has new low back pain and low-grade fever. She has pain into her bilat anterior thigh down her medial calf. Exam: strength is normal.
What is at the top of your ddx?
What dermatome is being affected?
What is your plan?
Osteomyelitis/osteodiscitis (infection) L4 MRI w/ contrast (use contrast for tumors or infections) 6 weeks IV abx CBC, ESR, CRP
