Spine MSK/Pain Flashcards
Steroid that is more likely to cause tissue atrophy with injection of superficial structures?
Triamcinolone
What type of allergy can interfere with hyaluronic acid injections?
bird products (eggs, poultry, feathers)
What are the natural curves of the spine?
- cervical lordosis
- thoracic kyphosis
- lumbar lordosis
- sacral kyphosis
What is “transitional anatomy” in the lumbar spine?
some people have sacralization of the lumbar spine or lumbarization of the sacrum resulting in 4 or 6 lumbar vertebrae respectively.
Does having “transitional anatomy” in the lumbar spine necessarily cause pain or is it a normal varient?
normal varient
What does the nucleus pulposus consist of?
Type II collagen, water, and other materials
What type of collagen makes up the annulus fibrosis?
type I
What nerves innervate the C4-C5 facet joint?
C4 and C5 medial branches of dorsal rami
What nerves innervate the L3-L4 facet joint?
L2 and L3 medial branches of dorsal rami
What provides innervation to the nucleus pulposus?
nothing, it lacks innervation.
What provides innervation to the annulus fibrosus?
- anterior: ventral rami
- posterior: sinuvertebral nerves
What provides innervation to the vertebral body?
sinuvertebral nerves
When is surgery indicated for a vertebral body compression fracture?
- greater than 25% loss of disc height
- spine is unstable
- significant neurologic deficits
What defines the middle column of the spine?
Posterior 1/3 of the vertebral body to the posterior longitudinal ligament
When is a spine unstable?
dammage to the middle column or any 2 columns
How does neurogenic claudication present?
- leg or buttock pain/weakness
- worse with prolonged standing
- worse with spinal extension and relieved with flexion
How does vascular claudication present?
- calf pain worse with activity (walking uphill, biking)
- skin changes (thin, shiny, hairless)
- diminished/absent pulses
Treatement for spinal stenosis
PT with directional preference assessment (flexion biased) or surgical decompression
Most common cause of spondylolisthesis?
Isthmic (Class II): fracture of pars interarticularis
How do you grade spondylolisthesis?
Treatment for spondylolisthesis?
- Grade 1, 2, and asymptomatic grade 3: rest and PT
- Symptomatic grade 3 or grade 4: surgery
What triggers SI joint pain?
transitional movements (sit to stand)
What does bilateral sacroiliitis indicate?
Ankylosing spondylitis
What type of radiculopathy will a L3-L4 central or posterolateral herniation cause?
L4
What type of radiculopathy will a L3-L4 lateral or neuroforaminal disc herniation cause?
L3
What type of radiculopathy will a C6/C7 disc herniation cause?
C7
What defines a disc bulge?
Disc tissue extending beyond the edges of the vertebral apophyses without displacement of disc material (nucleus)
What are the three types of disc herniation?
prolapse, extrusion, sequestration
What defines a disc protrusion?
displacement of disc material beyond the disc space with measure at base greater than apex
What defines a disc extrusion?
displacement of disc material beyond the disc space with measure at the apex greater than at the base
What defines a disc sequestration?
disc material has lost all connection with disc of origin
What is a schmorl node?
How are superior to inferior levels within a vertebral body defined?
In relation to the pedicle
How do we define the zones that a disc can herniate into?
What are the three types of annulus fissures?
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What is the return to work expectation (%) for a patient who has missed six months due to low back pain?
50%
what is an uncovertebral joint (joint of Luschka)?
disc degeneration creates raised superior lateral vertebral body margins (uncinate processes) that approximate with the vertebra above
From what levels does the supraspinous ligament run?
L3 to C7, above that it becomes the ligamentum nuchae
What is the cervical compression test?
reproduction of radicular symptoms with a downward compression on the top of the head
What is a Chymopapain injection designed to do?
dissolve subligamentous herniations contained by the PLL
What are some conditions on the differential for myelopathy?
tumors, MS, ALS, AV malformations, RA with subluxation, syringomyelia
What is the definiton of radiographic instability of vertebral segments on flexion/extension XRs?
- Cervical: greater than 3.5 mm translation
- Thoracic or Lumbar: greater than 5mm translation
- Rotation in sagittal plane more than 11 degree in the C-spine or 15 degrees in the L-spine
When is surgery indicated for scoliosis?
Cobb angle > 40 degree (35 if neuromuscular)
What is Scheuermann’s Disease?
an adolescent disorder of the vertebral endplates resulting in increased thoracic kyphosis
What defines a stable vertebral body burst fracture?
- Neurologically intact with posterior column intact
- Less than 50% collapse of anterior vetebral body height
Where does facet pain refer?
gold standard for diagnosis of facet pain?
double diagnostic medial branch blocks
What is the FABRE (Patrick’s) Test?
Contralateral SI joint pain with flexion, abduction, external rotation, and extension of the ipsilateral hip
What is the Gaenslen’s Test?
SI joint pain with extension of involved leg off the table while the contalateral hip is held in flexion.
What is the Iliac compression test?
SI joint pain with downward force on iliac crest with patient lying on their side
What is the Yeoman’s test?
SI joint pain with hip extension and ilium rotation
What is Gillet’s Test?
Failure of PSIS to rotate down on raised leg side due to SI joint restriction
What is the seated flexion test?
Asymmetric cephalad motion of the PSIS with forward flexion when seated. Abnormal side distinguished with standing flexion test.
most common location for spine infection?
thoracic spine
Mneumonic for Waddell’s signs?
DO ReST
- Distraction: lack of consistency between seated and supine straight leg testing
- Overraction: disproportionate reactions to a request
- Regionalization: abnormalities without anatomic basis
- Simulation: pain with light axial load or log rolling
- Tenderness: exaggerated sensitivity to touch
What are the two main nerve fibers that synapse onto wide dynamic range neurons in the dorsal horn?
- Large myelinated A Beta fibers carrying light touch and pressure
- Small unmyelinated C fibers carrying pain
What is the difference between CRPS I and II?
CRPS II is due to a know nerve injury (causalgia)
How long does the acute and dystrophic stages of CRPS last?
each stage last 3 - 6 months
Gold standard diagnostic test for CRPS?
stellate ganglion block
Early Tx for CRPS?
Prednisone 1mg/kg daily x 2 weeks
Three medications used to abort migrane headaches?
triptans, NSAIDs, acetaminophen
sensory distribution of nerves to the groin?
What is a trigger point?
hyperirritable band of tight muscle and fascia that causes pain and sensory changes
Where can you find the greater occipital nerve?
1/3 of the way from the occipital protuberance to the mastoid process
Where do you inject for a shoulder joint injection?
2 fingerbreadths medial and 2 fingerbreadts inferior to the posterior acromion aiming towards the coracoid process
type of collagen seen with tendonosis
III
Target for medial branch block?
junction of superior articular process and transverse process
target for stellate ganglion block?
transverse process of C6, anterior tubercle
What is the difference between vertebroplasty and kyphoplasty?
kyphoplasty introduces cement indirectly with use of a balloon and has additional goal of restoration of vertebral body height
Hyperesthesia
increased sensitivity to a stimulus
Hyperalgesia
Exaggerated pain response from a stimulus that normally elicitis pain
allodynia
pain elicited from a nonpainful stimulus
Where do C fibers terminate?
dorsal horn laminae I and II
Where are wide dynamic range neurons?
dorsal horn laminae III - V
What fibers inhibit pain responses in Gate Control Theory?
A-beta
Which opioid receptors cause respiratory depression?
Kappa, Mu2
What are the two metabolites of codine?
hydrocodone and morphine
Which opiate can contribute to serotonin syndrome? Why?
Tramadol because it is a weak NE/5HT reuptake inhibitor
Mechanism of action of buprenorphine?
- partial mu and kappa agonist
- delta antagonist
Two NSAIDs that are selective for COX-2?
Meloxicam and Celecoxib
Why should prescribing TCA’s in conjunction with SSRIs be avoided?
They are both metabolized by P450 in the liver, this can cause increased plasma levels of TCAs.
Where do lyrica and gabapentin act?
alpha 2 delta subunit of L-type calcium channels
What is a cordotomy?
ablation of the spinothalamic tract used to treat cancer pain
How is interstitial cystitis diagnosed?
potassium sensitivity test
Root levels of ilioinguinal and iliohypogastric nerves?
T12-L1
How do the different Modic changes show up on MRI?
- Type I: Bright on T2, dark on T1 due to serum/edema taking place of marrow
- Type II: Bright on both due to fat taking place of marrow
- Type III: Dark on both due to bony sclerosis
What are two mechanisms by which corticosteroids reduce pain?
- inhibit C-fiber excitation
- induce synthesis of phospholipase A2 inhibitor
How are alcohol and phenol related to CSF?
alcohol is hypobaric and phenol is hyperbaric
What are the borders of the “safe triangle” for transforaminal injections?
- Superior: horizontal line just under the superior pedicle
- Lateral: lateral edge of vertebral body
- Hypotneuse: spinal nerve root
Which type of epidural injection has the least risk for dural puncture?
caudal approach
What type of block is used to treat upper abdominal pain?
celiac plexus block
What type of block can treat pelvic pain from cancer?
superior hypogastric plexus block
Where is the hypogastric plexus located?
lower third of L5 vertebral body, anterolateral border bilaterally
