26. DJD of Spine Flashcards Preview

M2 Musculoskeletal > 26. DJD of Spine > Flashcards

Flashcards in 26. DJD of Spine Deck (38):
1

Rapid Association:

Clinical presentation of DISC HERNIATION

RADICULAR PAIN

(pain along the nerve root distribution)

2

Rapid Association:

Clinical presentation of DISC DEGENERATION

MECHANICAL BACK PAIN (axial +/- referred) 

 

3

Rapid Association:

Clinical presentation of SPINAL STENOSIS

NEUROGENIC CLAUDICATION 

4

Rapid Association:

Clinical presentation of DEGENERATIVE SPONDYLOLISTHESIS

MECHANICAL BACK PAIN (axial +/- referred)

RADICULAR PAIN

5

Rapid Association:

Clinical presentation of DEGENERATIVE SCOLIOSIS

MECHANICAL BACK PAIN (axial +/- referred) 

RADICULAR PAIN

6

The intervertebral discs are comprised of these 2 structures

nucleus pulposus + annulus fibrosis

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What is the nucleus pulposus?

function? 

composition?

how does this compare to the annulus fibrosis?

shock absorber of the spine

made of aggrecan (proteoglycans)+H2O in a matrix of Type II collagen and elastin fibers

(N looks like it has 2 parallel sticks..don't judge)

Annulus fibrosis - Type I collagen fibers 

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8

What is the purpose of the end plates on the vertebral bodies?

how do they change during one's lifetime?

serves as the growth plate for the vertebral bodies.

thick during infancy

thin during adulthood; becomes an avascular layer of hyaline cartilage

9

What happens if there is a loss of hydrostatic pressure in the disc?

example?

hydrostatic pressure normally collapses the small vessels.

A loss of hydrostatic pressure results in patent vessels that release NGF, which stimulates ingrowth of small, non-myelinated nerve fibers (nociceptive fibers) into the previously anervated areas of the disc - may be reaon why people experience axial pain.

examples: disc degeneration

10

How does the intervertebral discs change during one's lifetime?

be specific about nucleous pulposis and annulus fibrosis

infants:

  • nucleus: 90% water
  • annulus: rich in proteoglycans

over time: loss of water and proteoglycans

adults:

  • nucleus: smaller with altered biomechanics (results in increased forces on the annulus) 
  • annulus: stiffer, weaker 

11

what are 2 factors that play a role in the natural aging process of the intervertebral discs

  1. idiopathic loss of blood supply to the endplate
  2. non-enzyatic glycation - reduced sugars bind to collagen proteins and causes them to become more brittle + sticky -> disc becomes thicker, more fibrous
    • Also results in a yellowish brown color

12

how does disc degeneration occur? (3 steps)

what influences the progression of this? (4)

How does it present itself?

What is the outcome of disc degeneration?

  1. structural damage to end plate
  2. microfracture of endplate
  3. rupture of inner annulus and subsequent buldging of annulus into the nucleuos pulposis

factors: 

  • genetics
  • smoking
  • occupation
  • obesity

clinical presentation: MECHANICAL PAIN (axial + referrred) 

outcome: degenerative sciolosis

13

Wht are the 3 types of disc herniation? 

Who does it normally affect?

What usually causes it?

What are the 2 locations that it can occur?

What is the clinical presentation of disc herniation?

3 types:

  • protrusion/prolapse - herniated portion remains covered with a thin layer of peripheral annulus
  • extrusion – herniated portion ruptures thorugh the full thickness of the annulus and lies under the posterior longintudinal ligament or directly under the dural sac or nerve root
  • sequestration – herniated portion fragments away from the originating disc

USUALLY AFFECTS YOUNG ADULTS

Causes:

  • sudden violent trauma to a normal annulus
  • less severe trauma (bending, lifting) to a degenerated annulus

Locations

  • Postero-lateral
  • lateral

Clinical presentation:

  • RADICULAR PAIN (pain along the nerve root distribution) 

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POSTERIO-LATERAL disc herniation (Herniated Nucleus Pulposus)

Why does it happen here?

What does it affect?

What does it cause?

YOUNG adults

Posterio-lateral HNP common site due to thinness of annulus there

Affect: TRAVERSING NERVE ROOT

  • cervical spine: no traversing nerve root in the cervical spine, nerve roots exit above thier corresponding vertebrae. Thus C4/C5 HNP -> C5 compression
  • lumbar spine: remember that lumbar roots exit below their corresponding vertebrae. Thus, L4/L5 HNP in the posteriolateral corner results in L5 compression (weakness when walking on heels) - confusing but look at the diagram and it'll make sense.

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LATERAL disc herniation (Herniated Nucleus Pulposus)

What does it affect?

What does it cause?

  • affects EXITING nerve root 
    • L4/L5 HNP -> L4 nerve root compression

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16

How do you treat disc herniation? (2)

  • slow resolution of symptoms over 6-8 weeks in 80% of cases
  • failure to improve, or if there is progressive weakness/numbness = discectomy (surgery)





 

17

What is the physical outcome of disc herniation? 

 


RADICULAR pain (pain along the nerve root distribution)

  • C4/C5 herniation -> radicular pain along C5 dermatome
  • L4/L5 hernation - depends on location:
    • lateral: pain along L4 
    • posterio-lateral: pain along L5

+/- significant axial back pain
slow resolution of symptoms over 6-8 weeks in 80% of cases





 

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Who does Disc (Facet) degeneration usually affect?

What part of the spine is it most common in?

How does the disc height change early on? later?

What is the clinical presentation of this? (3)

  • middle aged patients
  • common in lumbar-sacral junction at L4/L5 and L5/S1 
  • Earlydisc height is minimally collapsed; ROM may be increased or decreased
  • Late: disc degeneration w. collapse of the disc height -> ROM is decreased

Clinical Presentation 

  • abnormal quality of motion (spinal instability)
  • activity related mechanical back pain (both axial and referred pain)
  • instability catch - sharp pain while bending forward or getting up from bent position

Treatment

  • fuse teh segment
  • total disc replacement
  • soft "dynamic" stabilization using a defice that restricts abnormal motion but does not fuse the segment

19

What is instability catch? 

Where do u see this in?

sharp back pain while bending forward or getting up from a bent position

Disc degeneration aka Facet degeneration

20

T/F  referred pain ≠ radicular pain 

T

radicular pain = dermatomal distribution of weakness or paresthesias in the area of the nerve root affected

referred pain = typically in the back + proximal thigh, but not of the nerve root..i think

21

Who does spinal stenosis usually affect? 

Why does it occur?

What is the clinical presentation of it? 

how do you test for it?

How do you treat it?

  • elderly
  • occurs as a result of the spine’s attempt to restabilize the disc degeneration by forming osteophytes around the margin of the disc and facet joints, leading to hypertrophy of the facet joints and osteophytes along the margin of the collapsed disc space 
     
  • Clinical presentation: neurogenic claudication – back and leg pain precipitated by standing for short periods of time (10-15min) but is relieved promptly by bending forward; shopping cart sign
  • Test: bicycle test - rarely provokes neuroenic claudication
  • Treatment
    • non-op/conservative: spinal epidural steroid injections due to presence of multiple comorbidities
    • decompression - laminectomy only if non-op treatment failed

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22

What does this patient suffer from?

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Spinal Stenosis (narrowing of the spinal canal)

typical shopping cart sign: neurogenic claudication – back and leg pain precipitated by standing for short periods of time (10-15min) but is relieved promptly by bending forward

23

Who does Degenerative Spondylolisthesis usually affect?

Where in the spinal cord does it usually affect? (2)

What is the clinical presentation? (3)

Treatment? 

  • middle age; women

  • scoliosis or stenosis commonly at L4/L5, L5/S1

    • L4/L5 g radicular pain in L4 dermatome

  • ​clinical presentation

    • activity-related mechanical back pain

    • constant baseline back pain

    • leg pain either in the form of

      • referred pain (in the back of the thigh)

      • radicular back pain (nerve root compressed under subluxated pedicle (due to exit foramen stenosis) or by the hypertropic facet joints

  • Treatment

    • laminectomy (decompress nerve roots to relieve leg pain) + fusion of the segment if the patient has chronic back pain

    • TDR (total disc replacement) is contraindicated because it may precipitate further instability

24

Who does Degenerative scoliosis usually affect?

Where is it most common? (1)

What is it caused by? (2-3)

What is the clinical prsentation of it? (3)

  • middle aged or elderly
  • common in the lumbar spine
     
  • caused by lateral listhesis + wedging/lateral tilt of the vertebra and slight rotation of the vertebral body
  • Clinical presentation
    • activity-related mechanical back pain (axial + referred)
    • radicular pain
    • spinal stenosis 

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25

A 35-year-male presents with pain radiating down the left leg, worse in the anterior leg distal to the knee. On physical exam, he is unable to go from a sitting position to a standing position with a single leg on the left, whereas he has no difficulty on the right. His patellar reflex is absent on the left, and 2+ on the right. Which of the following clinical scenarios would best produce this pattern of symptoms

Left L4-5 foraminal herniated nucleus pulposus

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26

A 62-year-old man presents with bilateral buttock and leg pain that is worse with prolonged standing and relieved with sitting. He denies symptoms with exercise on a stationary bike. Initial treatment including NSAIDS and an epidural steroid injection provided only temporary relief of his symptoms, which have returned and are now severe. On physical exam he has normal motor strength in his lower extremities, negative straight-leg raise tests bilaterally, and palpable bilateral dorsalis pedis pulses. Lumbar flexion-extension radiographs show no spondylolithesis or instability. What does he have and waht is the most appropriate next step in management?

Decompressive laminectomy with bilateral medial facetectomies and foraminotomies

he has spinal sciolosis.

27

A 71-year-old male presents with bilateral leg pain for the last two years. His pain is exacerbated when walking and is relieved when his sits or bends forward. He notes occasional periods where his legs feel weak, but motor examination reveals 5/5 motor strength throughout his bilateral lower extremities. He has diminished sensation on the medial aspect of his feet bilaterally. Management thus far has included NSAIDS with occasional narcotic usage, physical therapy, and two epidural steroid injections. He feels his pain is substantially worse than it was one year ago. What does he have and what is the most appropriate management at this time?

He has degenerative spondylolisthesis

Posterior L4-5 decompression with instrumented fusion of L4-5 

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is this helpful?

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hopefully. 

29

‘Neurogenic Claudication’ is typically characterized by

A.  Increased back and leg pain precipitated by sitting

B.  Pain is relieved by standing

C.  Associated with diminished peripheral pulse

D.  ‘Bending forward’ worsens pain

E.  Shopping-cart helps standing and walking longer

  

‘Neurogenic Claudication’ is typically characterized by

A.  Increased back and leg pain precipitated by sitting

B.  Pain is relieved by standing 

C.  Associated with diminished peripheral pulse 

D.  ‘Bending forward’ worsens pain 

E.  Shopping-cart helps standing and walking longer

30

‘Lumbar disc herniation ’ is common in

A.  Adolescents

B.  Young adults

C.  Elderly persons

D.  Male population

  

‘Lumbar disc herniation ’ is common in

A.  Adolescents 

B.  Young adults 

C.  Elderly persons 

D.  Male population

  

 

31

‘Degenerative Spondylisthesis’ is common in

A. Commonest in L5-S1 level

B. Usually exceeds Grade II listhesis

C. Common in female population

D. Typically presents with sciatic pain with minimal back pain

  

‘Degenerative Spondylisthesis’ is common in

A. Commonest in L5-S1 level 

B. Usually exceeds Grade II listhesis 

C. Common in female population 

D. Typically presents with sciatic pain with minimal back pain

32

‘Degenerative scoliosis’ typically

A.  Affects thoracic spine

B.  Associated with rotation of the vertebra towards convexity

C.  Caused by Lateral listhesis and wedging

D.  The deformity is usually flexible

  

‘Degenerative scoliosis’ typically

A.  Affects thoracic spine 

B.  Associated with rotation of the vertebra towards convexity 

C.  Caused by Lateral listhesis and wedging 

D.  The deformity is usually flexible

33

L4-5 postero-lateral disc herniation may typically present with

A.  L4 radicular pain

B.  Numbness in the bottom and outer border of the foot

C.  Absent knee reflex

D.  Weakness in walking on heels

  

L4-5 postero-lateral disc herniation may typically present with

A.  L4 radicular pain 

B.  Numbness in the bottom and outer border of the foot 

C.  Absent knee reflex 

D.  Weakness in walking on heels

 

34

L4-5 Degenerative spondylolisthesis causing radicular pain due to foraminal stenosis is typically follow

A.  L3 dermatome

B.  L4 dermatome

C.  L5 dermatome

D.  S1 dermatome

L4-5 Degenerative spondylolisthesis causing radicular pain due to foraminal stenosis is typically follow

A.  L3 dermatome 

B.  L4 dermatome 

C.  L5 dermatome 

D.  S1 dermatome

35

C4-5 Disc herniation causing radicular pain typically follow

A.  C 3 dermatome

B.  C 4 dermatome

C.  C 5 dermatome

D.  C 6 dermatome

C4-5 Disc herniation causing radicular pain typically follow

A.  C 3 dermatome 

B.  C 4 dermatome 

C.  C 5 dermatome 

D.  C 6 dermatome

36

After failed non-op treatment, acute lumbar disc herniation in the young patient, causing radicular leg pain with minimal back pain should be treated with

A.  Discectomy

B.  Decompression - laminectomy

C.  Decompression and un-instrumented fusion

D.  Decompression and Instrumented fusion  

After failed non-op treatment, acute lumbar disc herniation in the young patient, causing radicular leg pain with minimal back pain should be treated with

A.  Discectomy 

B.  Decompression - laminectomy 

C.  Decompression and un-instrumented fusion 

D.  Decompression and Instrumented fusion  

37

After failed non-op treatment, spinal stenosis in the elderly causing claudication leg pain with minimal back pain should be treated with

A.  Spinal fusion alone

B.  Decompression and fusion

C.  Decompression - laminectomy only

D.  Instrumented fusion

After failed non-op treatment, spinal stenosis in the elderly causing claudication leg pain with minimal back pain should be treated with

A.  Spinal fusion alone 

B.  Decompression and fusion 

C.  Decompression - laminectomy only 

D.  Instrumented fusion

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