the spine Flashcards
how many vertebrae are there?
- 33 total
- C7
- T12
- L5
- S5
- Coccyx 4
how many spinal nerves are at each level?
- C8
- T12
- L5
- S5
T4 dermatome
- nipple line
T10 dermatome
- belly button
L4 dermatome
- toes
S1 dermatome
- Achilles
what does AP view of c spine assess
- alignment
- rotation
what does lateral view of c spine assess
- alignment
- subluxation
- sponlyolysthesis
what does odontoid view of c spine assess
- used in trauma for C1- C2 clear space around odontoid
what does oblique view of c spine assess
- facet joints for spondylolysis
what does fuchs view of c spine assess
- modified odontoid through soft tissue of neck
what does swimmers view of c spine assess
- C6 C7 visualization in larger person
- arm close to cassett
odontoid fx
- aka peg or dens fx
- fx through odontoid process of C2
- most common fx of upper c spine
- mechanism variable but often d/t flexion loading
Associated injuries of odontoid fx
- atlas fx
- transverse ligament rupture- considered unstable
conservative tx for odontoid fx
- halo brace X 3 months
- will do well if pt is younger, small displacement, or dx early
operative tx for odontoid fx
- posterior atlantoaxial arthrodesis with wire and bone graft
- anterior screw fixation
cervical spondylosis
- combo of DDD and osteophyte formation
- common at C5-6* or C6-7
- DD and facet arthropathy -> radiculopathy
- often have associated disc herniation
- graded as levels 1-4
imaging for cervical spondylosis
- plain films to assess for alignment, disc space narrowing, anatomical anomalies
- MRI best but ONLY for interventional purposes
treatment for cervical spondylosis
- pain control- no narcs
- high dose steroids with taper
- PT
- light activity
- epidural steroid inj
- surgery - discectomy and fusion of affected vertebrae
herniated nucleus pulposis (HNP) in c spine
- neck pain that radiates or causes numbness
- radicular pain with compression of neural structures
- extremity weakness or numbness
- varying level of pain
- worse with flex/ ext
- often stiff and uncomfortable
- positive spurling’s sign
Hangman’s fracture
- noose placed with knot towards side of neck
- virtually never seen in suicide
- d/t hyperextension and distraction
- involves pars interarticularis of C2 bilaterally
clinical presentation of hangman’s fx
- often from post- traumatic neck pain after high velocity hyperextension (MVA)
- neurologic impairment not usually seen
radiographic findings for hangman’s fx
- bilat lamina and pedicle fx at C2
- associated anterolisthesis of C2 on C3
- ext of fx to transverse foramina- possible vertebral a injury
- CT best imaging modality
tx of hangman’s fx
- ABCs
- maintain c spine precautions
- treat other injuries
- early consult to spine/neuro
- hard collar first then soft collar
- ORIF
- halo brace
jefferson fx
- burst fx of C1 through anterior and posterior arches
- d/t axial loading which causes occipital condyles to be driven into lateral masses of C1
- i.e. diving head first into shallow pool
- not normally assoc with neuro deficits
- often associated with other C spine injuries and C2 fx
- possible vertebral artery injury
imaging of jefferson fx
- xray shows asymmetry in odontoid view with displacement of lateral masses away from dens
- significant displacement (>6 mm)= ligament injury
- CT to assess fx
- MRI if fx not seen and to eval ligament injury
treatment for jefferson fx
- if no transverse atlantal ligament injury then can tx with hard collar immobilization
- if ligament injury it is considered unstable -> halo immobilization, posterior C1-2 lateral mass internal fixation, transoral internal fixation
what does AP view of lumbar spine assess
- alignment and rotation
what does lateral view of lumbar spine assess
- alignment
- subluxation
- spondylolisthesis
what does coned down (spot) view of lumbar spine assess
- zooms in on L4 and L5
what does oblique view of lumbar spine assess
- articular facet
- pars interarticularis
- pedicles
LBP
- most common cause of disability in pts < 45
- second most common cause for PCP visit
- 80% resolves after 2 weeks
- 90% resolves after 6 weeks
si/sx of LBP
- sudden vs gradual onset
- usually around low back with radiation to buttocks
- +/- radiation to LE and radicular sx
- if radiates does it go past knee?
- +/- LE weakness (usually d/t pain)
physical exam for LBP
- if pt is more comfortable standing then do most of PE while theyre standing
- save maneuvers most likely to cause pain for last
- caution of waddell’s signs- correlate to non-organic LBP
what are Waddell’s signs?
- tenderness
- stimulation
- distraction
- regional
- overreaction
treatment for LBP
- pain control- no narcs
- PT
- light activity
surgical indications for LBP
- cauda equina syndrome- emergency
- HNP not responding to conservative tx
- cancer
- infection
- severe spinal deformity
HNP of lumbar spine
- LBP +/- radiation of pain and/or numbness
- L4-5 and L5-S1 most often affected
- pain with flexion or prolonged sitting
- radicular pain with compression of neural structures
- extremity weakness and pain
PE of HNP in lumbar spine
- pt may prefer to stand
- LBP at level of affected disc is worse with activity
- pain with flex or ext
- check motor, sensory and reflexes
- SLR on affected side, contralateral SLR is indicator for severe herniation
- must r/o cauda equina
sciatica
- shock like pain radiating down posterior aspect of legs often below the knees
imaging for HNP in lumbar spine
- xrays to assess alignment, disc space narrowing, OA, anatomic anomalies
- MRI best but ONLY for interventional purposes
treatment of HNP in lumbar spine
- pain control- limit narcs
- high dose PO steroids
- PT
- light activity
- epidural steroid injection
- discectomy
spondylolysis
- defects in pars interarticularis of neural arch that connects superior and inferior articular facets
- aka pars defect
- more common in men
- d/t stress fx or high energy trauma with hyperext of lumbar spine
- 90% occur at L5
- may be uni or bilat
clinical presentation of spondylolysis
- more in adolescent atheltic population- swimmers and gymnasts
- commonly asymptomatic
- if symptomatic have pain that is worse with ext and/or rotation of spine
- scotty dog sign on oblique view
treatment for spondylolysis
- sx often resolve with conservative tx
- bracing 6-8 months
- surgical repair if not responding to bracing or L5 pars defect
spondylolisthesis
- displacement of vertebral body in relation to inferior vertebra
- often at L5/S1* and L4/L5
- anterolisthesis or retrolisthesis
- graded by meyerding classification
meyerding classification
- grades spondylolisthesis
- Grade I= < 25% displaced
- grade II= 25-50% displaced
- grade III= 50-75% displaced
- grade IV= 75-100% displaced
- grave V= spondyloptosis
spinal stenosis
- narrowing of spinal canal
- mostly in older pts
- d/t OA, HNP, hypertrophy of ligamentum flavum, or congenital
clinical presentation of spinal stenosis
- pain worse with exertion
- reprod uni or bilat leg sx after walking several minutes
- relieved by sitting- neurogenic claudication
- pain usually worse when back ext to relieved by leaning forward
PE of spinal stenosis
- pt may prefer to sit
- limited ext and may produce pain down legs
- check motor, sensory, and reflexes
- SLR on affected side, contralateral SLR is indicator for severe stenosis
- need to r/o cauda equina
- xray first then MRI only for interventional purpose
treatment of spinal stenosis
- pain control- limit narcs
- PT
- light activity
- facet or epidural inj
- surgery- spinal decompression, nerve root decompression, spinal fusion
