Thoracic spine pain

Question 1

acute pain is often from?

Answer 1

compression fractures or muscle spasm

Question 2

what are the reasons for pain or deformity in young patients?

Answer 2

scoliosis and hyperkyphosis (scheueremann’s)

Question 3

what are the reasons for pain or deformity in adults?

Answer 3

chronic postural problems, long term scoliosis problems

Question 4

what are the reasons for pain or deformity in seniors?

Answer 4

compression fractures

Question 5

how do you tell between a T1 and a T2 weighted image?

Answer 5

T1: dark CSF
T2: white CSF

Question 6

red flags for thoracics

Answer 6

trauma, history of cancer, corticosteroid use, history of infection, drug or alcohol abuse
older: weight loss, history of cancer, night pain or fever

Question 7

when examining the thoracic spine, what should you look for?

Answer 7

deformity
skin lesions
AROM, PROM, Resisted ROM
prone extension test
Adam's test
palpate and percuss area of complaint
radiography if needed
specialized imaging if needed
labratory investigation if needed

Question 8

how do you tell the difference between osteoporosis, lytic mets or multiple myeloma?

Answer 8

old films, if not helpful, go to labs (CBC, ESR, C-RP, BCP, UA)

Question 9

if the labs look like they have lytic mets, what is going to happen next?

Answer 9

bone scan

if there are hot spots, do MRI, then biopsy

Question 10

if the labs look like they have multple myeloma, what is going to happen next?

Answer 10

PEP (protein electrophoresis), if there is an M spike, then they get a skeletal survey, then they get an MRI, then biopsy

Question 11

what is the most likely reason for pathological fracture in a child?

Answer 11

eosinophilic granuloma

Question 12

what cells are involved with eosinophilic granuloma?

Answer 12

langerhans cell histiocytosis (LCH)

Question 13

describe EG

Answer 13

proliferation of langerhans cells with an abundance of eosinophils, lymphocytes and neutrophils (produce prostaglandins, cause medullary bone resorption)
lesions may be ansymptomatic

Question 14

what are symptoms of EG if there are symptoms?

Answer 14

pain, swelling, tenderness around lesion

malaise, occasionally fever with leukocytosis

Question 15

describe osteoid osteoma demographic, pain and general location.

Answer 15

young male (10-25)
localized mid back pain
pain worse at night relievedby salicylates
metaphyseal region of long bones

Question 16

what are the signs and symptoms that can be in the thoracic spine?

Answer 16

postural problems
stiffness
deformity
scapular winging
Sprengel's deformity
buffalo hump 
dowager's hump
acute angle kyphosis
hyperkyphosis

Question 17

lower costovertebral pain can be referred pain from?

Answer 17

kidney

Question 18

mid thoracic/scapular pain can be referred pain from?

Answer 18

gallbladder

Question 19

thoracic sprain/strain
ortho
neuro
AROM 
PROM
radiography
recommendations

Answer 19

ortho: none
neuro: none
AROM: pain that contracts involved muscle
PROM: pain at end range of involved muscle or ligament
radiography: not required unless significan trauma
recommendations; myofascial therapy, limited orthotic support, ergonomic advice, preventative exercises and stretches

Question 20

neuritis or radiculitis signs and symptoms, ortho, neuro, aROM, PROM, recommendations

Answer 20

radiation along rib
pain radiate with valsalva
ortho: valsalva may increase pain
neuro: deficit in corresponding dermatome or myotome
AROM: variable weakness
PROM: variable
recommendations: MRI if no progression, limited orthotic support, myofascial therapy

Question 21

facet syndrome signs and symptoms, ortho, neuro, AROM, PROM, recommendations

Answer 21

signs and symptoms: may radiate along rib, but not usually, hyperextension increases local or radiating pain
ortho: Kemp’s or hyperextension
neuro: none
AROM: variable
PROM: variable
recommendations: myofascial therapy, limited orthotic support, ergonomic advice, preventative exercises and stretches, avoid hyperextension

Question 22

describe Scheuermann’s disease

Answer 22

13-17 years, slight male predominance
mid back pain and fatigue
increased kyphosis
vertebral growth plate trauma
anterior wedging greater than 5 degrees in 3 consecutive vertebra
decreased disc height and end plate irregularity

Question 23

what is the most likely place for scheuremann’s? second most common?

Answer 23

mid thoracic region (75%)
thoracolumbar region (25%)

Question 24

prone extension test

Answer 24

pt prone, place hands behind back, bring head up as far as you can

Question 25

prone extension test findings

Answer 25

persistence of kyphosis indicates structural kyphosis | if it improves, it is a functional kyphosis

Question 26

describe what to do with someone with scheuermann's

Answer 26

<60 degree curve- conservative, stretching, postural changes, hamstring stretching 60-80 degrees- brace >80 degrees- surgery

Question 27

when is an orthopedic consultation needed for scheuermann's?

Answer 27

when the patient is skeletally immature

Question 28

when can older patients get a compression fracture? Young patients?

Answer 28

older- could be a minor event (sneezing, stepping off curb, etc.) younger- fall on butt or hyperflexion injury)

Question 29

what are signs/symptoms of compression fracture?

Answer 29

sharp kyphotic angle pain on percussion and deep pressure anterior step defect and zone of impaction

Question 30

when is a fracture unstable?

Answer 30

when more than 1 column has decreased in height or iif the middle segment has flattened.

Question 31

radiographic features of osteoid osteoma

Answer 31

acute angle scoliosis lesion usually on concave side small density that surrounds a central radiolucent nidus bone scans or CT may be needed

Question 32

what needs to happen after an osteoid osteoma is confirmed?

Answer 32

``` complete surgical excision of the nidus little chance of recurrence vertebral body lesions may be irradiated percutaneous radiofrequency ablation is the preferred treatment option resolve spontaneously in ~33months ```

Question 33

what are the different possibilities of a missing pedicle?

Answer 33

congenital destructive surgical

Question 34

what are the different possibilities if the missing pedicle is destructive?

Answer 34

bone tumor (lytic mets, primary (ABC, osteoblastoma)) soft tissue tumor (neurofibroma) infection

Question 35

possible radiographic changes with infection

Answer 35

``` osteopenia soft tissue swelling decreased joint space lytic destructive changes periosteal reaction involucrum cloaca with potential draining sinus sequestrum sclerosis debris ankylosis ```

Question 36

herpes zoster

Answer 36

shingles acute, painful dermatomal dermatitis (blistering skin eruption) presence of immunosupression

Question 37

describe how herpes zoster occurs

Answer 37

virus travels from skin and mucosal surfaces to the sensory ganglia, lies dormant only reactivates with immunosupression, emotional stress, trauma, irradiation, surgical manipulation of spine

Question 38

signs and symptoms of herpes zoster

Answer 38

pain, blistering skin eruption with a dermatomal distribution nerve pain rash typically resolves in 2-4 weeks, nerve pain may continue for months to eyars after lesions have healed

Question 39

definition of a scoliosis

Answer 39

lateral deviation of >15 degrees and rotation of the spine, often associated with thoracic hypokyphosis severe disease distorts chest wall enough to restrict pulmonary and cardiovascular function cosmetic deformity may also be serious

Question 40

functional scoliosis

Answer 40

postural, compensatory reversible curve due to another condition (limb length, painful muscle spasm)

Question 41

structural scoliosis

Answer 41

nost postural, characterized by structural skeletal changes such as vertebral rotation and wedging and rib deformation

Question 42

idiopathic scoliosis

Answer 42

70-80% AKA familial scoliosis | not associated with dysmorphic features, skin lesions, bone fragility or neuromuscular disease

Question 43

congenital scoliosis

Answer 43

10%, errors of formation (hemivertebra) or errors of segmentation(unilateral bar, worsens gradually), commonly associated with genitourinary anomalies, curves present at birth, up to 75% require treatment

Question 44

neuromuscular scoliosis

Answer 44

15% associated with any disease that causes weakness of spastic imbalance of paraspinal muscles in growth child, including cerbral palsy, muscular dystrophy, spinal muscular atrophy, spinal cord injury; may develop at any age in growing child but doesn't occur after skeletal maturity

Question 45

dysmorphic syndrome (scoliosis)

Answer 45

neurofibromatosis, Marfan syndrome, Ehlers-Danlos syndrome, osteogenesis imperfecta, homocystinuria

Question 46

infantile scoliosis

Answer 46

by age 3, more common in boys and Europeans, usually resolves spontaneously

Question 47

juvenile scoliosis

Answer 47

4-10 years

Question 48

adolescent scoliosis

Answer 48

age 10 years until skeletal maturity, most significant and prevalent form, can become worse during growth spurt

Question 49

when do you send someone with a scoliosis to an orthopedist

Answer 49

if they have changed 5 degrees or more in a 3 month time period

Question 50

nash moe method

Answer 50

determines the rotational component of the vertebrae

Question 51

risser sign

Answer 51

``` risser 1- 1/4 of bone risser 2- 1/2 of bone risser 3- 3/4 of bone risser 4- all bone, not fused risser 5- all bone, fused ```

Question 52

when is someone considered a good surgical candidtate for scoliosis?

Answer 52

>50 degrees

Question 53

when do you send someone with scheuermann's to an orthopedist?

Answer 53

if they are still growing

Question 54

how do you determine osteoporosis from lytic mets from multiple myeloma?

Answer 54

history, clinical presentation, old films | if films are not helpful, do labs

Question 55

if the labs look like osteoporosis, what do you do?

Answer 55

adjust

Question 56

if the labs look like lytic mets, what do youdo?

Answer 56

bone scan MRI biopsy

Question 57

if the labs look lke multiple myeloma, what do you do?

Answer 57

PEP (urine and blood) skeletal survey MRI biopsy

Question 58

PET scan

Answer 58

positron emission tomography | radiotracer such as fluorodeoxyglucose (FDG), which contains both sugar and radioactive elements

Question 59

what happens physiologically if someone has eosinophilic granuloma?

Answer 59

proliferation of Langerhans cells with an abuncance of eosinophils, lymphocytes and neutrophils. the cells produce prostaglandins which result in medullary bone resorption

Question 60

what are some symptoms of eosinophilic granuloma

Answer 60

pain, swelling and tenderness around lesion | malaise, fever, leukocytosis

Question 61

what are the ddx for decreased disc height?

Answer 61

joint disease developmental infection

Question 62

what is the ddx of ivory vertebra?

Answer 62

blastic mets lymphoma pagets