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Musculoskeletal/Skin > 31 - Functional Spine Anatomy > Flashcards

31 - Functional Spine Anatomy Flashcards

1
Q

What are the components of a MSK spine exam?

A
  1. Inspection (observation)
  2. Palpation
  3. ROM
  4. Neuromusclar exam
  5. Special tests
  6. Examination of related areas (shoulder/cervical spine, Hip/lumbar spine)
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2
Q

What are the anterior bony landmarks/palpation spots of the cervical spine?

A

Hyoid bone: C3

Thyroid catrilage: C4-5

First cricoid ring: C6

Carotid tubercle: C6

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3
Q

What are the posterior bony landmarks/palpation spots of the cervical spine?

A

Occiput

Cervical spinous processes - C7 largest

Facet joints

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4
Q

How does the vertebral column structure confer function? How does this relate to injury?

A

The curve of the spine helps with movement.

More weight in the lumbar- can herniate

Cervical: increased mobility can cause problems

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5
Q

What are the components of a neuromusclar exam of the spine?

A
  1. Manual muscle testing
  2. Sensory testing
  3. Reflex testing
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6
Q

A 14 yo is diagnosed with flaccid paralysis to the right arm. There’s no pain, parethesis, or sensory loss. Lab results reveal polio virus infection. What is the target at which the polio virus aims to cause the pts symptoms?

A

The ventral horn of the spinal cord (just motor)

She is NOT having any sensory symptoms.

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7
Q

What type of innervation does each do: dorsal roots/doral horn, ventral roots/ventral horn, Ramis.

A

Dorsal roots, doral horn, DRG: all sensory

Ventral root or ventral horn: all motor

Ramis are MIXED nerves (a few exceptions) - motor and sensory

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8
Q

Defien myotome and dermatome?

A

Myotome: collection of muscle fibers innervated by the motor axons within each segmental nerve (root)

Dermatome: area of skin innervated by the sensory axons within each segmental nerve (root)

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9
Q

Describe the rash associated with herpes zoster (shingles)?

A

Acute neuralgia confined to the dermatome distribution of a specific spinal or cranial sensory nerve root.

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10
Q

Name the yellow labels?

A
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11
Q

What is the root level of the the thumb, long finger, and little finger?

A

C6 - thumb

C7 - long finger

C8 - little finger

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12
Q

What are the levels of manual muscle testing? Describe each?

A
  1. Normal strength: complete ROM against gravity with maximal resistance (examiner cannot overcome)
  2. Active movement against gravity and moderate resistance through full ROM (examiner can overcome)
  3. Active movement through full ROM against gravity (cannot do against resistance)
  4. Active movement through full RAM with gravity eliminated (can’t do full ROM against gravity)
  5. Flicker or trace of contraction, but no joint motion (no palpable muscle action)
  6. No contraction papated
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13
Q

Describe the numbers used to describe a neuromusclar exam?

A

0 - absent

1 - slight or less than normal (includes trace response or a response only brought out with reinforcement)

2 - lower half of normal range (low-normal)

3 - upper half of normal rane (high - normal)

4 - enhanced and more than normal (including clonus)

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14
Q

What is the Lhermitte’s sign?

A

Passive anterior cervical flexion elicits electric-like sensation down the spine or extremities.

Implies cervical spinal cord pathology.

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15
Q

What is a spurling neck compression test? What does it imply if positive?

A

Reproduction of radicular symptoms with cervical spinal extension, rotation, and lateral flexion.

Implies cervical nerve root pathology.

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16
Q

What is considered a positive test for a straight leg raising test (SLR or lasegue sign)?

A

Positive test is leg pain reprodued at 30-70 degree angle.

Implies lumbar nerve root pathology (L5 or S1)

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17
Q

What is the femoral nerve stretch test (upper lumbar disc)? What is considered a positive test and what does it imply?

A

Pt placed prone position while knee is flexed.

Positive test: reproduction of pts pain in anterior thigh

Implies upper lumber nerve root pathology (L2-L4)

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18
Q

What are signs of an UMN injury? What should this make you think?

A

Spasticity, hypertonicity, hyperreflexia, positive pathological reflexes, extensor plantar response.

THINK: spinal cord injury, brain injury/stroke, myelopathy, CNS lesion.

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19
Q

What are signs of an LMN injury? What should this make you think?

A

Flaccid weakness, loss of reflexes (hyporeflexia), muscle wasting and atrophy.

THINK: peripheral nerve entrapment, radiculopathy.

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20
Q

What are red flags to make you think of a patient having a malignancy?

A

History of cancer

Unexplained weight loss

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21
Q

What are red flags that make you think that someone has a spinal fracture?

A
  • Major trauma
  • Minor trauma or strenous lifting in an older/osteoporotic person
  • Prolonged corticosteroid use
  • Osteoporosis
  • Advanced age >70yrs
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22
Q

What are red flags that make you think that someone has an infection?

A
  1. Constitutional symtpoms (fever, chills)
  2. Recent bacterial infections (UTI or skin infections, pneumonia)
  3. Immunosuppression
  4. IV drug use
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23
Q

What are red flags that make you think that someone has cauda equina syndrome?

A
  1. Acute onset urinary incontinence/retention
  2. Fecal incontinence, loss of anal sphincter tone
  3. Saddle anesthesia
  4. Global/progressive weakness in lwoer limbs
24
Q

What is the etiology of lumber strain? What is seen on exam?

A

Axial low back pain after acute injury, such as lifting or twisting; pain worse with movement, better with rest. Muscle disruption from excessive stretch or tension.

Exam: localized mucsle tenderness, reduced ROM, normal neuro exam.

25
Q

What is the treatment of lumbar strain?

A

Relative rest: bedrest >48 hrs NOT recommended

Pain control with NSAIDS/muscle relaxant

Manual therapy (chiro)

PT

NO imaging

Majority is self-limited

26
Q

What is the common history seen with a disc herniation? What makes it better or worse?

A

Acute injury/event or can be insidious. Limb pain > axial spine pain

May have numbness/tingling; may have weakness.

Worse:

  • lumbar: sitting, bending, cough/sneeze
  • cervical: ROM

Better:

  • lumber: standing, walking
  • cervical: lying
27
Q

What is seen on exam of someone with a disc hernation?

A

Myotomal weakness, dermatomal pain/numbness/tingling.

Decreased or absent reflex of affected nerve.

Spurling or SLR positive.

28
Q

If a disc herniation is between C5 and C6, which nerve is being compressed?

A

C6

For lumber and cervical levels - it’s the nerve number of the lower vertebrea.

29
Q

What causes radiculopathy? What locations are commonly affected?

A

Posterolateral herniation - most common: posterior longitudinal ligament (PLL)

Cerical spine: C6, C7 most affected

Lumbar spine: L5, S1 most affected

30
Q

What are some mechanisms of nerve root compression?

A
  • Neural ischemia, increased intraneural pressure
  • Edema of nerve root, DRG
  • Dura is mechanically sensitive

Biochemical irritation of nerve root: nucleus pulposis contains cytokines, leukotrienes, COX2, interleukin-1, TNF-a. Can cause apoptosis of DRG cells.

31
Q

Describe the pain radiation, reflex, sensation, and motor weakness associated with a C5 radiculopathy?

A

Pain radiation: shoulder blade, lateral arm

Reflex: biceps

Sensation: lateral arm

Motor weakness: shoulder flexion and abduction, elbow flexion

32
Q

Describe the pain radiation, reflex, sensation, and motor weakness associated with a C6 radiculopathy?

A

Pain: shoulder blate, radial arm, and forearm

Reflex: brachioradialis

Sensation: radial distal arm and forarm, thum

Motor weakness: Elbox flexion, forarm pronation, wrist extension

33
Q

Describe the pain radiation, reflex, sensation, and motor weakness associated with a C7 radiculopathy?

A

Pain radiation: Posterior arm and forearm

Reflex: triceps

Sensation: posterior arm and dorsal forearm, middle finger

Motor weaknes: elbox extension, wrist flexion

34
Q

Describe the pain radiation, reflex, sensation, and motor weakness associated with a C8 radiculopathy?

A

Pain radiation: medial arm and forearm

Reflex: NA

Sensation: medial forarm, 4th and 5th fingers

Motor weakness: finger flexion and abduction

35
Q

Describe the pain radiation, reflex, sensation, and motor weakness associated with a L4 radiculopathy?

A

Pain radiation: anterior thigh and knee, medial calf

Reflex: patellar

Sensation: anterior thigh, and medial calf/foot

Motor weakness: knee extension, ankle dorsiflexion

36
Q

Describe the pain radiation, reflex, sensation, and motor weakness associated with a L5 radiculopathy?

A

Pain radiation: buttocks, lateral thigh and calf, dorsal foot and great toe

Reflex: medial hamstring

Sensation: lateral leg and dorsum of foot

Motor weakness: angle dorsiflexion, great toe extension

37
Q

Describe the pain radiation, reflex, sensation, and motor weakness associated with a S1 radiculopathy?

A

Pain radiation: posterior thigh and calf, lateral/plntar foot

Reflex: achilles

Sensation: posterior calf, lateral foot

Motor weakness: ankle planter flexion

38
Q

What are some treatments for disc herniation?

A

Modify activity but avoid bedrest

Pain meds: NSAIDs, neuromodulators, possible short course prednisone

PT

Epidural steroid injection for pain control

39
Q

What are indications for surgical treatment (discectomy) of a disc herniation? Is this usually needed?

A

Progressive weakness

Refractory symptoms

Bowel/bladder dysfunction

Myelopathy

70-85% improve w/out surgery

40
Q

What is an early xray finding of ankylosing spondylitis?

A

Ragged joints; as they progress they may fuse entirely

41
Q

What are early and late signs of ankylosing spondylitis?

A

Early: widening of SI joints with adjacent sclerosis compatible with sacroiliitis. Posterior longitutubal ligament sclerosis at L1-L2, L2-L3.

Late: fuciton of SI joints compatible with advanced sacroiliitis; symmetric syndesmophytes bridging all vertebral bodies causing “bamboo spine”. Ossification of the anterior, posterior, and interspinous longitudinal ligaments

42
Q

What is ankylosing spondylitis? Who gets it?

A

Chronic inflammatory disease with progressive involvement of the SI and axial skeletal joints.

  • Enthesitis (inflamm of sites where tendons or ligaments insert into the bone), chondritis, osteitis
  • 3:1 mle to female
  • Can cause aortitis and cardiac problems
43
Q

What history is usually seen with ankylosing spondylitis? What will labs show?

A

Slowly progressive low back pain and stiffness; worst in the month and with prolonged inactivity. Better with exercise.

Will be tender over SI joints.

Labs show: elevated CRP, sed rate, 90% HLAB27 +

Treat with NSAIDs, PT, anti-TNFa agents if severe.

44
Q

What is seen on hisotyr with facet joint arthropathy? What is the etiology? How is it treated?

A

Axial low back pain, gradual onset. Cervical worse with extension. Lumbar worse with standing/walking. Better with sitting or lying.

  • Gradual degenerative changes/OA to facet joints
  • Pain with extension, relief with flexion

NSAIDs, PT, consider steroid injections

45
Q

What is seen on history of lumbar stenosis? What is the etiology?

A

Slow, progressive pain in the back and unilateral or bilateral legs. Worse when standing, walking. Relieved with lumbar flexion (+ shopping cart sign).

Usually in >55yo

No focal findings.

Etiology: narrowing of spinal canal from disc, thickening of bone, facet joints, spondylolithesis, or thicking of ligamentum flavum.

46
Q

What is the treatment for lumbar stenosis?

A

PT

Gait ait - walker facilitates mild flexion

NSAIDs, neuromodulators

Surgical if pain is intolrrable

47
Q

Where do compression fractures usually occur? Who gets them?

A

Majority in ppl with osteoporosis, prolonged corticosteroid use, consider multiple myeloma in patients younger than 55 with compression fracture.

48
Q

How do compression fractures in young vs old people differ?

A

Compression fractures in young people can be caused by multiple myeloma and they are not the wedge shaped we just talked about, they are just crushed.

Compression fractures in old people is usually caused by osteoporosis

49
Q

What is seen on history and exam of a compression fracture?

A

History: sudden onset thoracic or lumbar pain

Exam: local tenderness, painful lumbar ROM (esp flexion), normal neuro exam unless nerve affected

50
Q

How would you image and treat a compression fracture?

A

Image: Xrays, consider MRI or CT (better visualization of acuity on MRI or CT) If malig suspected: CBC, SPEP, alk phos, ESR

NSAIDs, APAP, calcitonin, mild opioids. Consider bracing 6 weeks.

51
Q

What history is seen with cauda equina syndrome? What is the etiology? What is seen on exam? What is the treatment?

A

History: back pain, leg pain, numbness, weakness, saddle anesth., bowel, bladder dysfunction.

Etiology: large herniated disc compressing cauda equina

Exam: reduced or absent reflexes, weakness, decreased rectal tone

SURGICAL EMERGENCY!!!

52
Q

What history is seen with cervical myolopathy?

A

Typically >50 yo, subtle and varied presentation which requires a high index of suspicion.

Loss of fine motor skills/hand clumsiness. Gait disturbance. Motor weakness. LE numbness, weakness, pain.

53
Q

What is seen on exam with cervical myolopathy?

A

UE and LE with predominantly PMN findings and weakness below the level of cord involvement.

  • hyperrflexia in upper and lower limbs
  • hoffman’s sign, + babinski, clonus
  • Lhermitte sign may be present
  • Rhomberd sign

Wide based ataxis shuffling, slow gait.

54
Q

What is the etiology of cervical myopathy?

A

Cervical cord compression, usually gradual progression due to posterior osteophyte formatoin, spinal stenosis.

55
Q

What is the treatment for cervical myelopathy?

A

Surgical treatment almost always indicated - cervical decompression (laminectomy)

  • May not correct neuro deficits but will prevent progression

Musculoskeletal/Skin (29 decks)

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