Spine Pain Flashcards
Incidence
- 5th MC presentation to the office
- female > male
- most prevalent 45-64 years of age
- sedentary lifestyle
- manual labor
- lower economic status
- lower education
- smoking status
- body habitus
How does smoking status affect spine pain??
Causes osteoporosis and degenerative changes in the discs; slows healing
Impact
#1 work related #1 MCC of disability #2 MCC of missed work
Recall the 3 segments of the back
-vertebra # and curvature
- cervical
- 7 vertebra
- lordosis - thoracic
- 12 vertebra
* *rib attachment (except for T12): -kyphosis - lumbar
- 5 vertebra
- lordosis - sacral
- 5 fused vertebra attached to the ilium via the sacro-iliac joints - coccyx/tailbone
- 4 fused vertebra
Which region has the lowest chance of disc herniation?
Thoracic d/t connections to the ribs and thin discs
What are the 5 structural causes of pain?
- loss of cervical lordosis: degenerative
- exaggerated thoracic kyphosis: idiopathic or degenerative
- hyperlordosis of the lumbar region
- flat back syndrome
- scoliosis: idiopathic vs degenerative
Define spinous process
-common injury
connection of ligaments (interspinous ligament and the supraspinous ligament
**it is ruptured in many traumatic fractures
Define lamina
bony connection between the spinous process and the transverse process
Define facet
joint that connects the vertebra
Define transverse process
-common injury
connection of ligaments (intertransverse ligament) and tendon for muscle attachment
**common bone for traumatic fracture
Define pars
-common injury
area between the superior articular facet and the pedicle
**common area of idiopathic and traumatic injury
Define ligamentum flavum
ligament from the skull to the sacrum that stabilizes the spine
Define pedicle
connection between the posterior elements and the anterior elements
What is the role of the intervertebral disc?
-composition
- the shock absorbers of the spine
- composed of annulus fibrosus and nucleus pulposis
Which 2 ligaments function in spine stabilization?
Posterior longitudinal ligament and anterior longitudinal ligament
What are the 2 “openings” in a vertebra?
Spinal canal and intervertebral foramen
If a patient has an injury in C4-C6, where will the pain radiate?
between the shoulder blades
Where does T4 dermatome run?
Breast/nipple line
Where does T10 dermatome run?
Umbilicus
Nerve root C5
-sensations
-lateral arm
Nerve root C6
-sensations
-radial forearm, thumb, and index finger
Nerve root C7
-sensations
-middle finger
Nerve root C8
-sensations
-ulnar, forearm, small finger
Nerve root T1
-sensations
-medial arm
Nerve roots L1,L2
-sensations
- inguinal crease (L1)
- anterior thigh (L2)
Nerve roots L2, L3
-sensations
- anterior thigh (L2)
- anterior thigh just above knee (L3)
Nerve root L4
-medial leg and foot
Nerve root L5
-lateral leg, foot dorsum
Nerve root S1
-lateral leg, plantar foot
What should you ask in history?
- location
- frequency
- duration (is it constant or does it come and go?)
- previous history (if yes, how did you treat last time?)
- extremity pain (radicular sx point to nerve root issue)
What are red flags in a history? (many)
- advanced age
- H/o osteoporosis
- fever
- recent infection
- IV drug abuse
- trauma
- bowel/bladder or saddle anesthesia
- weight loss
- H/o cancer
Why is bowel/bladder/saddle anesthesia a red flag??
Sudden onset indicates Cauda equina syndrome –> medical emergency!
*If it’s not repaired quickly, it will not be able to be reversed
When should you get xray?
- red flag signs
- prolonged symptoms
- gross abnormalities on exam
When should you get MRI (with or without contrast)?
- prolonged radicular symptoms in a patient that would consider pain management or surgery
- gross neurologic signs
**WITH CONTRAST: suspicion of cancer, infection or hardware in the area of imaging
When should you get CT?
- trauma
- pt unable to have MRI (pacemaker, spinal cord stimulators, old aneurysm clips)
When should you get CT myelogram?
-if pt is unable to have MRI and you want to look at nerves
Non-specific spine pain
-cervical strain/sprain
- whiplash: extreme hyperextension, hyperflexion (injury to ALL and interspinous)
- muscle overuse or abuse: i.e. holding phone to your ear
Non-specific spine pain
-lumbar strain/sprain
-muscle overuse or abuse: usually lifting/twisting or fall
You should reserve imaging for…
high suspicion of fractures! If you think it’s just sprain/strain, avoid imaging.
S/Sx of non-specific spine pain
- sharp pain
- pain with movement
- decreased range of motion
- swelling
- whiplash: may include dizziness, headaches that last for months
Treatment of non-specific spine pain
-meds
- NSAIDS
- muscle relaxants (short term)
- narcotics (short term)
- steroids (controversial)
Treatment of non-specific spine pain
-conservative
- bracing
- cold/heat
- physical therapy (massage, stretching, ultrasound, TENS, traction)
- chiropractor
- acupuncture
Categories of mechanical spine pain
- degenerative
- congenital
- herniated/bulging disk
- spinal stenosis
- fractures
Degenerative spine pain
-risk factors
-age
-smoking
-family history-
sports
-manual labor
-body habitus
Degenerative spine pain
-conditions
- discogenic pain
- spondylosis
- spondylolysis
- spondylolisthesis
Degenerative spine pain
-tx
- smoking cessation
- weight loss
- core strengthening: low impact exercise, swimming, yoga, pilates
- bracing
- PT: including massage, ultrasound, TENS, etc.
- chiropractor/acupuncture
Which meds are first line in degenerative spine pain??
NSAIDs
Degenerative spine pain
-pain management
- IDET (intradiscal electrothermal therapy): heat to annulus causing collagen to contract
- stem cell implant: patient generated stem cell injection to disc
Degenerative spine pain
-surgery
- artificial disc replacement: motion preservation: works best in cervical spine
- fusion: as effective in lumbar as motion preservation, definitive treatment for dynamic spondylolisthesis
Explain congenital kyphosis
degenerative due to osteoporosis and compression fractures
**may need surgery to stabilize fractures
Define Scheuermann’s kyphosis
young adults with kyphosis and wedge deformities on xray
**may need surgery if organs are at risk
What are the 2 MC congenital scoliosis?
- C curve or S curve
- mostly originate in thoracic spine
Scoliosis in children vs. adults
- children MC congenital: progressive with development and may interfere with organ development and self appearance; needs surgery
- adult: degenerative- may require surgery if progresses and debilitating pain
Define bulging disc
nucleus pulposis still in the confines of the annulus
Define herniated disc
nucleus pulposis thru the annulus, may be protruded or extrusion
Where in spine is bulging/herniation MC found?
cervical and lumbar
**rarely ever thoracic
Axial and radicular sx for bulging/herniation
- dermatomal patterns: pain or paresthesia
- strength
- muscle atrophy
- deep tendon reflexes
Bulging/herniation tx
-meds
- NSAID
- muscle relaxants
- narcotics
- neuropathics (tricyclics, neurontin/lyrica, cymbalta)
- oral steroids
Bulging/herniation tx
-pain management
- epidural steroid injections (no more than 3 per year)
- selective nerve root blocks
Bulging/herniation tx
-surgery
- Laser
- Foraminotomy/Hemilaminectomy/ Discectomy
- Disc Replacement
- Fusion
Pros/cons to laser surgery
shrink the disc herniation to relieve pressure from the nerve VARIABLE results and no covered by many insurance plans
Pros/cons to foraminotomy/hemilaminectomy/ discectomy
decompress, scar tissue may continue to cause pain, may cause iatrogenic instability, high risk of re-herniation
Pros/cons to disc replacement
may cause hypermobility in the lumbar spine, MOST effective in single level cervical spine
Cause of spinal stenosis
usually caused by both anterior and posterior element conditions resulting in near complete obliteration of central spinal canal
***progressive, degenerative disease
S/sx of spinal stenosis
- progressive degenerative disease
- progressive decrease in the ability to ambulate
- “shopping cart” sign
- decreased deep tendon reflex
Tx of spinal stenosis
- water therapy
- epidural steroid injections
- decompressive laminectomy
- decompression Fusion
S/sx of cauda equina/foot drop
Cauda Equina Syndrome
- lower extremity weakness
- urinary retention or incontinence
- bowel incontinence
- saddle anesthesia
- spaghetti sign?
Foot Drop
-inability to dorsiflex foot
What usually causes cauda equina syndrome?
acute onset of complete occlusion of the spinal canal usually due to a large disc herniation below the L3 level
S/sx of cervical myelopathy
-increased risk of paralysis
-clumsiness:
Dropping objects
Working with small objects
Poor handwriting
Hand numbness
-gait Instability:
“Drunk” walk
-muscle atrophy of the hands
Cervical myelopathy PE
- sx worsen on extension of the cervical spine
- decreased proprioception of the hands
- hyper-reflexia of the upper and lower extremities
- (+) Hoffman’s sign
What is Hoffman’s sign???
- for UMN lesion
- “Babinski of the upper extremity”
- if you flick the long finger, the index and thumb will flex and adduct
Tx of cervical myelopathy
**surgical urgency to prevent progression and possible paralysis
- Posterior Decompression and Fusion: if multiple levels
- Anterior Cervical Discectomy and Fusion (ACDF): if compression is less than 3 levels and due to disc herniation not bony position
- ACDF with Corpectomy: may need to remove one or more vertebral body if bony position is responsible for canal occulsion
List the common fractures (8)
- Compression: MC
- Jefferson: C1
- Odontoid: C2
- Hangman: C1/C2
- Teardrop: both extension and flexion
- Chance
- Burst
- Coccyx
Etiology of compression fractures
- elderly
- osteopenia/osteoporosis
- female > male
- steroid use
- trauma
- very common at thoraco-lumbar junction (T12-L2)
Compression fracture
-exam
- pain at the level of the fracture
- kyphosis at the site of the fracture
- balance issues
- radiculopathy
Compression fracture
-tx
- conservative: medication, activity modification and bracing
- vertebroplasty/kyphoplasty
- fusion
Jefferson fracture
- axial loading injury causing a C1 ring injury
- increased risk of artery injury
- may be associated with ligamentous and C2 injury
- needs immobilization and possible surgery
Odontoid (Dens) Fracture
3 types
*C2 fracture
3 types
I: tip of the dens
II: base of the dens
III: through the lateral mass requires surgery
Hangman’s fracture
- traumatic spondylolisthesis C2-3
- hyperextension and distraction
- 3 types
- treated from collar to surgery based on type and deficit
Teardrop fractures
-extension
- extension with avulsion of fragment
- usually C2
- collar
*MC seen in whiplash or d/t trauma (think car accident)
Teardrop fractures
-flexion
- usually C5-6
- flexion and axial loading
- most severe
- paralysis
*think cliff divers
Chance fracture
- flexion/distraction injury
- usually thoracolumbar junction
- common cord or conus injury
- frequent intra-abdominal injuries
- TLSO and/or Surgery
*think seat belt injury of fall from significant height
Burst fracture
- similar to compression but bone breaks in multiple spots
- bracing with possible surgery (if still in pain after 12 weeks)
Coccyx Fracture
- tailbone fracture
- donut/cushion
- surgery = infection
Referred spinal pain
- AAA
- pelvic disease
- gastrointestinal disease
- renal
Non-mechanical spinal pain
-neoplasia
- Multiple Myeloma
- Metastasis
- Spinal cord Tumors
- Vertebral Tumors
Non-mechanical spinal pain
-inflammatory arthritis
- Ankylosing Spondylitis
- IBS
- Autoimmune Arthritis
Multiple myeloma is d/t…
Over growth of Plasma Cells in the Bone Marrow
Multiple myeloma s/sx
- bone pain
- leukopenia/thrombocytopenia/anemia
- increase osteoclast formation resulting in pathologic fractures
- hypercalcemia
- infection
- kidney disease
What lab results correlate with multiple myeloma?
- MGUS (monoclonal gammopathy of undetermined significance)
- M proteins in blood (SPEP) / Bence Jones proteins in urine***
Metastatic tumor etiology
- spine is 3rd MC site
- intradural mets uncommon
- majority affect bone
- common primary cancers: lung, breast, colon, lung, prostate
- more than 70% to the thoracic spine
Metastatic tumor tx
radiation, surgery
*outcome poor
Extramedullary spinal cord tumors are…
typically benign, growth has occurred on a nerve root
Types of extramedullary spinal cord tumors
- meningiomas: arise from dura mater
- schwannomas: nerve sheath tumor
- neurofibromas: nerve sheath tumor
- filum terminale ependymomas: arise from the lower lumbar/sacral- causes tethering and pain
Intramedullary spinal cord tumors are…
typically malignant
Types of intramedullary spinal cord tumors
- astrocytomas: glial origin; children
- ependymomas: glial origin: adults
Benign vertebral tumor types
- osteoid osteoma; children; posterior elements; small; painful scoliosis
- osteoblastoma: children- posterior elements; large; recurrent
- giant cell tumor: young adult; rare and aggressive**
Malignant vertebral tumor types
- **osteogenic sarcoma: teenager, nighttime pain
- chordoma: rare; slow growing; mostly in sacrum (neural tube)
- chondrosarcoma: 30% of skeletal tumors; origin is cartilage: resistant to chemotherapy and radiation
- ewing’s sarcoma: teenagers; pelvis
Inflammatory arthritis - ankylosing spondylitis etiology
- men > female
- begins in early adulthood
- morning pain and stiffness
- typically starts in sacroiliac joint, pt comes in c/o pain
- bamboo spine
What lab finding corresponds with ankylosing spondylitis?
HLA B27***
Common complication of ankylosing spondylitis
uveitis
Ankylosing spondylitis tx
- NSAID
- TNF blockers (Humira, Enbrel, Remicade)
- Physical therapy
Trochanteric bursitis etiology
- pain along the Greater Trochanter
- can’t sleep on the side of the pain
- tx with steroid injection into the bursa
Sacroiliac joint pain etiology
- pain with external rotation of the hip
- usually bilateral
- tx with steroid injections into the joint and physical therapy
Piriformis syndrome
- piriformis muscle compresses sciatic nerve
- worse with sitting, climbing stair, walking or running
