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Musculoskeletal 1 > Spine Pain > Flashcards

Spine Pain Flashcards

1
Q

Incidence

A
  • 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
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2
Q

How does smoking status affect spine pain??

A

Causes osteoporosis and degenerative changes in the discs; slows healing

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3
Q

Impact

A 
#1 work related
#1 MCC of disability
#2 MCC of missed work
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4
Q

Recall the 3 segments of the back

-vertebra # and curvature

A
  1. cervical
    - 7 vertebra
    - lordosis
  2. thoracic
    - 12 vertebra
    * *rib attachment (except for T12): -kyphosis
  3. lumbar
    - 5 vertebra
    - lordosis
  4. sacral
    - 5 fused vertebra attached to the ilium via the sacro-iliac joints
  5. coccyx/tailbone
    - 4 fused vertebra
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5
Q

Which region has the lowest chance of disc herniation?

A

Thoracic d/t connections to the ribs and thin discs

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6
Q

What are the 5 structural causes of pain?

A
  1. loss of cervical lordosis: degenerative
  2. exaggerated thoracic kyphosis: idiopathic or degenerative
  3. hyperlordosis of the lumbar region
  4. flat back syndrome
  5. scoliosis: idiopathic vs degenerative
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7
Q

Define spinous process

-common injury

A

connection of ligaments (interspinous ligament and the supraspinous ligament

**it is ruptured in many traumatic fractures

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8
Q

Define lamina

A

bony connection between the spinous process and the transverse process

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9
Q

Define facet

A

joint that connects the vertebra

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10
Q

Define transverse process

-common injury

A

connection of ligaments (intertransverse ligament) and tendon for muscle attachment

**common bone for traumatic fracture

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11
Q

Define pars

-common injury

A

area between the superior articular facet and the pedicle

**common area of idiopathic and traumatic injury

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12
Q

Define ligamentum flavum

A

ligament from the skull to the sacrum that stabilizes the spine

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13
Q

Define pedicle

A

connection between the posterior elements and the anterior elements

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14
Q

What is the role of the intervertebral disc?

-composition

A
  • the shock absorbers of the spine

- composed of annulus fibrosus and nucleus pulposis

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15
Q

Which 2 ligaments function in spine stabilization?

A

Posterior longitudinal ligament and anterior longitudinal ligament

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16
Q

What are the 2 “openings” in a vertebra?

A

Spinal canal and intervertebral foramen

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17
Q

If a patient has an injury in C4-C6, where will the pain radiate?

A

between the shoulder blades

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18
Q

Where does T4 dermatome run?

A

Breast/nipple line

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19
Q

Where does T10 dermatome run?

A

Umbilicus

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20
Q

Nerve root C5

-sensations

A

-lateral arm

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21
Q

Nerve root C6

-sensations

A

-radial forearm, thumb, and index finger

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22
Q

Nerve root C7

-sensations

A

-middle finger

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23
Q

Nerve root C8

-sensations

A

-ulnar, forearm, small finger

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24
Q

Nerve root T1

-sensations

A

-medial arm

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25
Q

Nerve roots L1,L2

-sensations

A
  • inguinal crease (L1)

- anterior thigh (L2)

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26
Q

Nerve roots L2, L3

-sensations

A
  • anterior thigh (L2)

- anterior thigh just above knee (L3)

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27
Q

Nerve root L4

A

-medial leg and foot

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28
Q

Nerve root L5

A

-lateral leg, foot dorsum

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29
Q

Nerve root S1

A

-lateral leg, plantar foot

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30
Q

What should you ask in history?

A
  • 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)
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31
Q

What are red flags in a history? (many)

A
  • advanced age
  • H/o osteoporosis
  • fever
  • recent infection
  • IV drug abuse
  • trauma
  • bowel/bladder or saddle anesthesia
  • weight loss
  • H/o cancer
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32
Q

Why is bowel/bladder/saddle anesthesia a red flag??

A

Sudden onset indicates Cauda equina syndrome –> medical emergency!
*If it’s not repaired quickly, it will not be able to be reversed

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33
Q

When should you get xray?

A
  • red flag signs
  • prolonged symptoms
  • gross abnormalities on exam
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34
Q

When should you get MRI (with or without contrast)?

A
  • 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

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35
Q

When should you get CT?

A
  • trauma

- pt unable to have MRI (pacemaker, spinal cord stimulators, old aneurysm clips)

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36
Q

When should you get CT myelogram?

A

-if pt is unable to have MRI and you want to look at nerves

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37
Q

Non-specific spine pain

-cervical strain/sprain

A
  • whiplash: extreme hyperextension, hyperflexion (injury to ALL and interspinous)
  • muscle overuse or abuse: i.e. holding phone to your ear
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38
Q

Non-specific spine pain

-lumbar strain/sprain

A

-muscle overuse or abuse: usually lifting/twisting or fall

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39
Q

You should reserve imaging for…

A

high suspicion of fractures! If you think it’s just sprain/strain, avoid imaging.

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40
Q

S/Sx of non-specific spine pain

A
  • sharp pain
  • pain with movement
  • decreased range of motion
  • swelling
  • whiplash: may include dizziness, headaches that last for months
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41
Q

Treatment of non-specific spine pain

-meds

A
  • NSAIDS
  • muscle relaxants (short term)
  • narcotics (short term)
  • steroids (controversial)
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42
Q

Treatment of non-specific spine pain

-conservative

A
  • bracing
  • cold/heat
  • physical therapy (massage, stretching, ultrasound, TENS, traction)
  • chiropractor
  • acupuncture
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43
Q

Categories of mechanical spine pain

A
  • degenerative
  • congenital
  • herniated/bulging disk
  • spinal stenosis
  • fractures
44
Q

Degenerative spine pain

-risk factors

A

-age
-smoking
-family history-
sports
-manual labor
-body habitus

45
Q

Degenerative spine pain

-conditions

A
  • discogenic pain
  • spondylosis
  • spondylolysis
  • spondylolisthesis
46
Q

Degenerative spine pain

-tx

A
  • smoking cessation
  • weight loss
  • core strengthening: low impact exercise, swimming, yoga, pilates
  • bracing
  • PT: including massage, ultrasound, TENS, etc.
  • chiropractor/acupuncture
47
Q

Which meds are first line in degenerative spine pain??

A

NSAIDs

48
Q

Degenerative spine pain

-pain management

A
  • IDET (intradiscal electrothermal therapy): heat to annulus causing collagen to contract
  • stem cell implant: patient generated stem cell injection to disc
49
Q

Degenerative spine pain

-surgery

A
  • artificial disc replacement: motion preservation: works best in cervical spine
  • fusion: as effective in lumbar as motion preservation, definitive treatment for dynamic spondylolisthesis
50
Q

Explain congenital kyphosis

A

degenerative due to osteoporosis and compression fractures

**may need surgery to stabilize fractures

51
Q

Define Scheuermann’s kyphosis

A

young adults with kyphosis and wedge deformities on xray

**may need surgery if organs are at risk

52
Q

What are the 2 MC congenital scoliosis?

A
  • C curve or S curve

- mostly originate in thoracic spine

53
Q

Scoliosis in children vs. adults

A
  • 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
54
Q

Define bulging disc

A

nucleus pulposis still in the confines of the annulus

55
Q

Define herniated disc

A

nucleus pulposis thru the annulus, may be protruded or extrusion

56
Q

Where in spine is bulging/herniation MC found?

A

cervical and lumbar

**rarely ever thoracic

57
Q

Axial and radicular sx for bulging/herniation

A
  • dermatomal patterns: pain or paresthesia
  • strength
  • muscle atrophy
  • deep tendon reflexes
58
Q

Bulging/herniation tx

-meds

A
  • NSAID
  • muscle relaxants
  • narcotics
  • neuropathics (tricyclics, neurontin/lyrica, cymbalta)
  • oral steroids
59
Q

Bulging/herniation tx

-pain management

A
  • epidural steroid injections (no more than 3 per year)

- selective nerve root blocks

60
Q

Bulging/herniation tx

-surgery

A
  • Laser
  • Foraminotomy/Hemilaminectomy/ Discectomy
  • Disc Replacement
  • Fusion
61
Q

Pros/cons to laser surgery

A

shrink the disc herniation to relieve pressure from the nerve VARIABLE results and no covered by many insurance plans

62
Q

Pros/cons to foraminotomy/hemilaminectomy/ discectomy

A

decompress, scar tissue may continue to cause pain, may cause iatrogenic instability, high risk of re-herniation

63
Q

Pros/cons to disc replacement

A

may cause hypermobility in the lumbar spine, MOST effective in single level cervical spine

64
Q

Cause of spinal stenosis

A

usually caused by both anterior and posterior element conditions resulting in near complete obliteration of central spinal canal

***progressive, degenerative disease

65
Q

S/sx of spinal stenosis

A
  • progressive degenerative disease
  • progressive decrease in the ability to ambulate
  • “shopping cart” sign
  • decreased deep tendon reflex
66
Q

Tx of spinal stenosis

A
  • water therapy
  • epidural steroid injections
  • decompressive laminectomy
  • decompression Fusion
67
Q

S/sx of cauda equina/foot drop

A

Cauda Equina Syndrome

  • lower extremity weakness
  • urinary retention or incontinence
  • bowel incontinence
  • saddle anesthesia
  • spaghetti sign?

Foot Drop
-inability to dorsiflex foot

68
Q

What usually causes cauda equina syndrome?

A

acute onset of complete occlusion of the spinal canal usually due to a large disc herniation below the L3 level

69
Q

S/sx of cervical myelopathy

A

-increased risk of paralysis
-clumsiness:
Dropping objects
Working with small objects
Poor handwriting
Hand numbness
-gait Instability:
“Drunk” walk
-muscle atrophy of the hands

70
Q

Cervical myelopathy PE

A
  • sx worsen on extension of the cervical spine
  • decreased proprioception of the hands
  • hyper-reflexia of the upper and lower extremities
  • (+) Hoffman’s sign
71
Q

What is Hoffman’s sign???

A
  • for UMN lesion
  • “Babinski of the upper extremity”
  • if you flick the long finger, the index and thumb will flex and adduct
72
Q

Tx of cervical myelopathy

A

**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
73
Q

List the common fractures (8)

A
  1. Compression: MC
  2. Jefferson: C1
  3. Odontoid: C2
  4. Hangman: C1/C2
  5. Teardrop: both extension and flexion
  6. Chance
  7. Burst
  8. Coccyx
74
Q

Etiology of compression fractures

A
  • elderly
  • osteopenia/osteoporosis
  • female > male
  • steroid use
  • trauma
  • very common at thoraco-lumbar junction (T12-L2)
75
Q

Compression fracture

-exam

A
  • pain at the level of the fracture
  • kyphosis at the site of the fracture
  • balance issues
  • radiculopathy
76
Q

Compression fracture

-tx

A
  • conservative: medication, activity modification and bracing
  • vertebroplasty/kyphoplasty
  • fusion
77
Q

Jefferson fracture

A
  • 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
78
Q

Odontoid (Dens) Fracture

3 types

A

*C2 fracture

3 types
I: tip of the dens
II: base of the dens
III: through the lateral mass  requires surgery

79
Q

Hangman’s fracture

A
  • traumatic spondylolisthesis C2-3
  • hyperextension and distraction
  • 3 types
  • treated from collar to surgery based on type and deficit
80
Q

Teardrop fractures

-extension

A
  • extension with avulsion of fragment
  • usually C2
  • collar

*MC seen in whiplash or d/t trauma (think car accident)

81
Q

Teardrop fractures

-flexion

A
  • usually C5-6
  • flexion and axial loading
  • most severe
  • paralysis

*think cliff divers

82
Q

Chance fracture

A
  • 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

83
Q

Burst fracture

A
  • similar to compression but bone breaks in multiple spots

- bracing with possible surgery (if still in pain after 12 weeks)

84
Q

Coccyx Fracture

A
  • tailbone fracture
  • donut/cushion
  • surgery = infection
85
Q

Referred spinal pain

A
  • AAA
  • pelvic disease
  • gastrointestinal disease
  • renal
86
Q

Non-mechanical spinal pain

-neoplasia

A
  • Multiple Myeloma
  • Metastasis
  • Spinal cord Tumors
  • Vertebral Tumors
87
Q

Non-mechanical spinal pain

-inflammatory arthritis

A
  • Ankylosing Spondylitis
  • IBS
  • Autoimmune Arthritis
88
Q

Multiple myeloma is d/t…

A

Over growth of Plasma Cells in the Bone Marrow

89
Q

Multiple myeloma s/sx

A
  • bone pain
  • leukopenia/thrombocytopenia/anemia
  • increase osteoclast formation resulting in pathologic fractures
  • hypercalcemia
  • infection
  • kidney disease
90
Q

What lab results correlate with multiple myeloma?

A
  • MGUS (monoclonal gammopathy of undetermined significance)

- M proteins in blood (SPEP) / Bence Jones proteins in urine***

91
Q

Metastatic tumor etiology

A
  • 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
92
Q

Metastatic tumor tx

A

radiation, surgery

*outcome poor

93
Q

Extramedullary spinal cord tumors are…

A

typically benign, growth has occurred on a nerve root

94
Q

Types of extramedullary spinal cord tumors

A
  • 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
95
Q

Intramedullary spinal cord tumors are…

A

typically malignant

96
Q

Types of intramedullary spinal cord tumors

A
  • astrocytomas: glial origin; children

- ependymomas: glial origin: adults

97
Q

Benign vertebral tumor types

A
  • osteoid osteoma; children; posterior elements; small; painful scoliosis
  • osteoblastoma: children- posterior elements; large; recurrent
  • giant cell tumor: young adult; rare and aggressive**
98
Q

Malignant vertebral tumor types

A
  • **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
99
Q

Inflammatory arthritis - ankylosing spondylitis etiology

A
  • men > female
  • begins in early adulthood
  • morning pain and stiffness
  • typically starts in sacroiliac joint, pt comes in c/o pain
  • bamboo spine
100
Q

What lab finding corresponds with ankylosing spondylitis?

A

HLA B27***

101
Q

Common complication of ankylosing spondylitis

A

uveitis

102
Q

Ankylosing spondylitis tx

A
  • NSAID
  • TNF blockers (Humira, Enbrel, Remicade)
  • Physical therapy
103
Q

Trochanteric bursitis etiology

A
  • pain along the Greater Trochanter
  • can’t sleep on the side of the pain
  • tx with steroid injection into the bursa
104
Q

Sacroiliac joint pain etiology

A
  • pain with external rotation of the hip
  • usually bilateral
  • tx with steroid injections into the joint and physical therapy
105
Q

Piriformis syndrome

A
  • piriformis muscle compresses sciatic nerve

- worse with sitting, climbing stair, walking or running

Musculoskeletal 1 (14 decks)

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