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MSK II - Exam 1 > Spine- Thoracolumbar VII- Stenosis thru Anomalies > Flashcards

Spine- Thoracolumbar VII- Stenosis thru Anomalies Flashcards

1
Q

What is stenosis?

A

Narrowing around and compression of neurological structures

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2
Q

What is the MOST common diagnosis of for spinal surgery in adults??

A

Stenosis in adults over 60 years of age

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3
Q

What population is stenosis most common in?

A
  • typically over 65 years of age
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4
Q

Why can younger people get stenosis?

A

Spondylolisthesis

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5
Q

What percentage of asymptomatic individuals have canal narrowing on imaging?

A

30%

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6
Q

Is compression from outside in unilateral or bilateral?

A

Unilateral> bilateral and central

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7
Q

What is compression from outside in due to?

A
  • age-related disc and joint changes MOST commonly
  • instability - older or younger individuals
  • enfolding of ligamentum flavum (likely need sx)
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8
Q

What causes compression from inside out?

A
  • sheath around nerve is fibrotic due to persistent inflammation
  • increased blood supply to nerve with activity, particularly walking, causes nerve to enlarge
  • Fibrotic nerve wont expand, compression results from inside out
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9
Q

Compression from inside out is the same result as __________ but a different mechanism

A

Narrowing

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10
Q

What structures are involved with ischemic compression and venous congestion?

A
  • spinal nerve
  • radicular arteries supply spinal nerve
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11
Q

What is the spinal nerve for segment L3,4?

A

L4

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12
Q

What is the spinal nerve for segment L4,5?

A

L4 and L5

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13
Q

What is the spinal nerve for L5,S1?

A

L5-S2

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14
Q

What are the symptoms of lateral stenosis?

A
  • Unilateral LE > LBP with segmental paresthesias and gripping type pain due to ischemia
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15
Q

What decreased LE>LBP with stenosis?

A

FB/sitting/AM

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16
Q

What increases LE> LBP with stenosis?

A

Standing/walking and possibly coughing/sneezing if acute

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17
Q

Are symptoms worse with level walking or an incline with stanosis?

A

Level walking

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18
Q

What are signs we will find in our observation with lateral stenosis?

A
  • slouched
  • possible scoliosis
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19
Q

What will we find with ROM with lateral stenosis?

A

-Flexion/ Contralateral side bend decreased LE and LBP but may demonstrate limited motion due to NOT being able to open lateral foramen
- Extension/ipsilateral SB increased LE and LBP and may also demonstrate limited motion due to contact with spinal nerve
- rotation inconsistently produces symptoms

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20
Q

What will we find with neuro testing with lateral stenosis?

A

likely positive for radiculopathy

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21
Q

What will we find with stress tests with lateral stenosis?

A

Possible positive PA pressure/torsion when sustained

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22
Q

What will we find with accessory motion with lateral stenosis?

A
  • hypomobility
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23
Q

Where will hypomobility in accessory motion testing be?

A
  • in adjacent joints, lower thoracic, upper lumbar, and/or LE especially HIP
  • In lumbar flexion and contralateral SB to open lateral foramen
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24
Q

What will be impaired with lateral stenosis? (muscle type)

A

impaired local muscle stabilization

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25
Q

What special tests can we do for lateral stenosis?

A
  • stability tests
  • LE discrepancies
  • balance deficits
  • Cooks CPR
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26
Q

What are we looking for with stability tests with lateral stenosis?

A

Possible excessive shearing

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27
Q

What type of LE discrepancies are we looking for with lateral stenosis?

A
  • leg length discrepancy
  • impaired mechanics
  • etc.
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28
Q

What can we see with balance deficits with lateral stenosis?

A
  • wide based gait
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29
Q

What are cooks CPR special tests?

A
  • bilateral symptoms
  • LE pain over LBP
  • standing/walking pain
  • pain relief with sitting
  • over 48 years of age
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30
Q

Whats the criteria for cooks special test?

A

4/5 LR+ = 4.6
1/5 LR- = .19

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31
Q

Will compression or distraction be positive for lateral stenosis?

A
  • compression positive
  • distraction negative and possibly relieving

** only with sustained hold

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32
Q

Why does no lymphatic veins in PNS or CNS impact stenosis?

A
  • body cant pull swelling off as efficiently, can lead to extended inflammatory phase
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33
Q

What can central stenosis possibly indicate?

A
  • possibly spinal cord if above L1/2, if lower can be cauda equina, which is multiple spinal nerves, which leads to LMN S&S
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34
Q

Why can the hip especially be hypomobile with lateral stenosis?

A

if it doesnt extend, body will compensate with lumbar extension which can make lateral stenosis worse

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35
Q

How can we differentiate neural vs vascular cases of stenosis?

A
  • Ankle brachial index test for possible peripheraial arterial disease (PAD)
  • bicycle test
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36
Q

What does the ankle brachial index test?

A
  • ratio of tibial and brachial arteries
  • normal is .9-1.3
  • .41-.9 is mild to moderate
  • less than or equal to .4 is severe
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37
Q

What is the bicycle test? what does it look for?

A
  • cycling upright in slight extension then bending to lean on handlebars for three minutes each
  • if stenosis, pain with decrease with bent position, if it does not PAD is indicated
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38
Q

Why can a larger lateral spur be problematic with stenosis?

A
  • one large lateral spur could affect multiple spinal nerves because they are positioned more vertical compared to cervical spine where it would take multiple levels of spurring
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39
Q

Why is there no change with SB or Rotation with central stenosis?

A

these movements dont change the size of the central foramen

40
Q

What are the classic S&S of cauda equina syndrome?

A
  • incontinence (bowel and bladder dysfunction, LMN S&S)
  • Saddle paresthesias
41
Q

What is the PT rx directed at?

A

Foraminal opening

42
Q

What can we educate the patient about regarding stenosis?

A
  • pt education of foramen and good prognosis
43
Q

What else beside pt education can we do to direct foraminal opening for patients with stenosis?

A
  • directional preference into flexion
  • intermittent traction may be helpful with radiculopathy, esp if no centralization
  • manual therapy
  • neural mobilizations if gliding restrictions
44
Q

What sub group is manipulation most effective for?

A

Stenosis with LBP

45
Q

What areas can we do manual therapy / manipulation on with stenosis?

A
  • lower thoracic
  • lumbar manipulation MOST effective with exercise
  • evidence of support for addition of hip joint manipulation
46
Q

When is lumbar manipulation for stenosis MOST effective?

A

When combined with exercise

47
Q

What kinds of MET can we do for stenosis to open the foramen?

A

Aerobic
* unweighted walking
* cycling as effective as un-weighted walking
* primary influence may be on circulation improvements

Balance training

local muscle stabilization

48
Q

When can we start balance training with stenosis patients?

A
  • ONLY as able to be upright without symptoms
  • this position causes symptoms, start with seated balance training
49
Q

Which is better? Corsets or no corsets for stabilization?

A

Corsets better than no corsets

50
Q

Why can corsets be helpful for stenosis?

A

Increases vertical seperation, can create a small amount of space and relieve compression

51
Q

What are surgery indications with stenosis?

A
  • presence of constant and/or worsening symptoms
  • failure to obtain relief with 3-6 months of non-surgical treatments
52
Q

Is there a BEST surgery for stenosis?

A

inconclusive best surgery

53
Q

Which surgeries are considered effective for stenosis?

A

Spinal decompression of laminectomy and/or partial discectomy with or without fusion

54
Q

What is better with surgery for stenosis? Not better?

A
  • Benefit with pain/disability but walking distance NOT better
55
Q

Is the outcome different with surgery vs PT if just stenosis?

A

Outcome can be like comprehensive PT if just stenosis

56
Q

What is the improvement with surgery for stenosis with spondylolythesis?

A

Substantially greater pain relief and improvement in function vs. PT at 4 years

57
Q

What is spondylolysis?

A

Bony defect or fracture in pars interarticularis unilaterlly or bilaterally

58
Q

What is the etiology of spondylolysis?

A
  • excessive and repetitive extension, particularly when combined with rotation
  • congenital (could be aymptomatic)
  • direct trauma
59
Q

What is the prevelance of spondylolysis?

A
  • highest in adolescent athletes
  • biological males over females
60
Q

Why does spondylolysis affect adolescent athletes?

A
  • as we grow vertically the bone density drops, takes time to fill in bone properly to meet demand
61
Q

What are risk factors for spondylolysis?

A
  • MOST common: athletics
  • low vitamin D in ~75% of cases
  • Genetics/ Bony morphology
  • excessive lordosis (loads bone more)
62
Q

What are the structures most commonly involved with spondylolysis?

A

MOST at L5, S1
- secondarily at L4,5

63
Q

What are S&S of spondylolysis?

A
  • like a worse case of instability S&S
  • possible fracture S&S
  • conditions leading to low vitamin D
64
Q

What is spondylolisthesis?

A

Anterior vertebral segment slippage

65
Q

How many types of spondylolisthesis?

A

5, 2 most common

66
Q

What are the two most common types of spondylolisthesis?

A
  • isthmic or adolescent with spondylolysis
  • degenerative
67
Q

What is the MOST common type of spondylolisthesis?

A

Isthmic or adolescent with spondylolysis

68
Q

What causes adolescent spondylolisthesis?

A
  • age group with MOST rapid slipping
  • mechanism of action: repetitive or traumatic extension
69
Q

What is degenerative spondylolisthesis due to?

A
  • due to age-related disc changes and occurs after the 5th decade
  • NO fracture
70
Q

What are the degrees of slippage with spondyloisthesis?

A
  • grade 1 = 0-25%
  • grade II = 26-50%
  • grade III = 51-75%
  • grade IV = 76-100%
71
Q

What are S&S of spondylolisthesis?

A
  • like worse case of instability
  • possible lateral or central stenosis S&S with slippage
  • NO correlation with slippage and degree of symptoms
71
Q

Can a grade I spondyloisthesis have more symptoms than a grade III?

A

YES

71
Q

What is PT rx for spondylolysis and spondylolisthesis?

A
  • like a worse case of hypermobility/instability
72
Q

What is the MET outcomes with spondylolysis and spondylolisthesis?

A

better outcomes with 10 weeks of local muscle training vs traditional therex alone out to 1.5 years

73
Q

What is the prognosis for spondylolysis and spondylolisthesis?

A
  • healing greater in unilateral lesion vs bilateral lesion

> 84% of young adults improved after 1 year with up to 25% slippage
92% of adolescents returned to sport within 6 months

74
Q

How can such a large percentage of young adults improve after 1 year?

A
  • better with early intervention and unilateral lesion
  • not dependent on lesion healing
75
Q

Why does LBP return in around half of the cases of spondylolysis and spondylolisthesis?

A
  • stress fracture doesnt heal, so improved symptoms get aggitated later on and comes back
76
Q

When is surgery indicated with spondylolisthesis?

A

Confirmed imaging without conservative benefits

77
Q

What are surgical outcomes for spondylolisthesis?

A
  • 83% excellent to good outcomes with modified scott technique vs others (fusion)
78
Q

What is there strong evidence of with acute IDD and extension?

A

short term benefit with LE symptoms and centralization occurs

79
Q

What is the benefit of extension with persistent IDD?

A
  • short term benefit
80
Q

What is extension directional preference NOT superior to with persistent IDD?

A
  • NOT superior vs stabilization exercises
  • NOT superior vs combined manual therapy and non-stabilization exercise
  • NO difference in pain and function vs no intervention at all
81
Q

Just because a disc change is noted, is it causing the symptoms?

A

NO, not in up to 2/3 of cases

82
Q

What can reduced circulation cause within the muscle?

A
  • may cause up to 300 mm Hg of pressure within the muscle
83
Q

What percentage of a muscle contraction with reduce circulation?

A
  • a 30% max voluntary contraction of the muscle will reduce circulation
84
Q

What percentage of a muscle contraction will nearly eliminate circulation?

A

A 70% MVC of the muscle

85
Q

Why is proper posture and regular change of positions helpful for circulation?

A

Allows proper blood flow

86
Q

What does a flexed and depressed posture do to the diaphragm?

A

Compresses diaphragm
- actively overworked and insufficient with persistent LBP
- thoracic extensors and accessory respiratory muscles overwork to compensate

87
Q

What does a decreased anti-gravity reflex of muscles lead to?

A

Local muscle inhibition

88
Q

What muscle is smaller in those with persistent neck pain?

A

Transversus abdominus

89
Q

What happens to the load on the lumbar region with every anterior inch of FHP?

A

Load doubles

90
Q

What is the PT rx for sitting FHP and msk issues?

A
  • posture/ergonomic
  • education: sit tall and be supported by chair
  • Diaphragmatic breathing to minimize accessory respiratory muscles
  • MT/MET in thoracolumbar regions to improve mobility
  • MET to improve local muscle functions in thoracolumbar regions
91
Q

What fusions are anomalies?

A
  • Congenital and autolytic
92
Q

What are the types of congenital fusions?

A
  • lumbarization (6 lumbar vertebra, S1 doesnt fuse with sacrum)
  • Sacralization ( 4 lumbar vertebra, L5 fuses with sacrum, 1 less vertebra)
93
Q

What are the autolytic fusions due to?

A
  • due to age-related joint disease
  • spurring bridges and fuses joints

MSK II - Exam 1 (7 decks)

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