Flashcards in Back and Neck Disorders Stowell Deck (81):
What is the MC cause of work disability?
Low back pain
Cause of low back pain
Unable to determine in most cases
70-90% of low back pain cases are:
Nonspecific (aka mechanical)
Majority of low back pain cases resolve within:
Various causes of low back pain
-Non specific (70%)
-Ortho pathology (25%)
Inflammatory arthritis causing low back pain is often a/w:
What are examples of orthopedic pathology that can cause low back pain?
-Degenerative changes (OA)
What clinical factors increase probability of neoplasm causing low back pain?
1. Previous history of non-skin cancer
2. Age over 50
3. Unexplained wt loss
4. Failure of conservative tx for LBP
Etiologies of infection causing low back pain?
-Vascular insufficiency (DM)
-Hematogenous seeding (S aureus)
What clinical features suggest ankylosing spondylitis?
-Age less than 40
-Duration more than 3 months
-Symptoms improve w/easy exercise
-Not relieved w/rest
What PE findings can be found with ankylosing spondylitis?
-Limited chest expansion
-Limited lumbar ROM
Imaging findings of ankylosing spondylitis
-Grading of sacroilitis
-Bamboo sign (fusing of vertebral bodies)
Describe the HLA-B27 gene and its relation to AS
-Normal finding in 8% of Caucasians
-Only 2% of people w/the gene will develop AS
-So it is NOT diagnostic for AS
-Can be a finding though
What abnormal lab is found in 70% of patients with AS?
What is cauda equina syndrome (CES)?
-Compression of lower spinal nerve roots
-Impairs motor and sensory function to lower extremities and bladder
What is the MC finding a/w CES?
What is saddle anesthesia and what is it a/w?
-Unable to feel anything in body areas that sit on a saddle
Define degenerative joint disease (DJD)
Term used interchangeably with osteoarthritis (OA)
Define degenerative disc disease
-Degenerative changes of disc
-Reduced ability to maintain fluid flow (loss of disc height)
-Can be a source of chronic LBP
-Joint stiffness d/t disease or surgery
-Union of proximal/distal bones of joint
Gradual progression of disc degeneration and articular cartilage mechanical breakdown
What dynamic is altered in OA?
Cartilage/disc fluid (decreased ability to absorb/distribute mechanical stress)
What joint alterations occur with OA?
-Osteophytes (bone spurs)
-Decreased disc height
Why/how do osteophytes (bone spurs) form in OA?
-Secondary to facet joint dysfunction
-Body's way of trying to splint or limit use of joint
-Joints above and below will suffer additional/abnormal mechanical forces
Clinical features of OA
-Age over 50
-Worse in AM or after prolonged rest
-Relieved w/light activity
MOI for OA
-Prolonged postural activity (painting, gardening)
*Usually not acute trauma
What is the common ROM pattern with OA?
-Extension (side bending) feels worse
-Flexion feels better
What imaging confirms OA?
Plain film x-ray (AP and lat)
How do labs present in OA?
What is a disc bulge?
-Herniated nucleus pulposa (HNP)
-May or may not compress/stretch a nerve root (asymp or symptomatic)
Define discogenic pain
Nociceptors in disc generate pain to back/LE
If a disc bulge compresses the nerve root, what is produced?
Spinal nerve root impingement d/t space occupying lesion in vertebral canal or IVF
MC lumbar radiculopathy
L5 and S1 followed by L4
Possible causes of radiculopathy
-Herniated nucleus pulposa
-Lumbar spinal stenosis
Disc herniation w/radiculopathy ROM pattern
Flexion makes it worse (provokes radicular symptoms)
OA vs. disc herniation w/radiculopathy ROM patterns
-Flexion feels better in OA
-Flexion feels worse in radiculopathy
Motor and reflex findings of disc herniation w/radiculopathy
-Motor: weakness of myotome of involved nerve root
-Reflex: diminished DTR of involved nerve root
2 common neural tension tests to assess radicular symptoms
-Straight leg raise (supine)
-Slump test (sitting)
Imaging for diagnosis of disc herniation w/radiculopathy
Not indicated! Unless red flags or need to rule in or out other
Non-surgical management of disc herniation w/radiculopathy
-OTC pain meds (often not good enough)
-Epidural steroid injections
-McKenzie Method (centralization technique by PTs and chiropractors)
-Patient education for coping
Surgical management of disc herniation w/radiculopathy
Pros of surgical management of disc herniation w/radiculopathy
-Pts w/dominant leg pain can have excellent results
-85-90% return to full function
Cons of surgical management of disc herniation w/radiculopathy
Up to 15% of patients have continued back pain that may limit their return to full function
Define spinal stenosis
Narrowing of vertebral canal and/or IVF
Causes of spinal stenosis
-Disc, tumor, cyst
How does spinal stenosis present?
-Age over 55-60 yrs
-Radiating leg pain that gets worse with downhill walking (extension worsens it)
-LE symptoms consistent w/neurogenic claudication (relieved forward flexion)
-May or may not have back pain
Surgical treatment of spinal stenosis
-X stop implant
-Laminectomy (decompress the nerves)
-Fusion (if unstable segments)
Describe X stop implant
-Spinal stenosis surgery
-Titanium wedge inserted b/w spinous processes
-Permanent but does not attach to bone or ligaments
Defect in pars interarticularis of a vertebra
-Defect in pars interarticularis of a vertebra
-WITH anterior displacement of the vertebra
Stiffening or fusing of joint (often from degenerative changes)
Classifications of spondylolisthesis
Type 1: congenital
Type 2: isthmic (classic presentation of adolescent patient)
Type 3: degenerative
Type 4: traumatic
Type 5: pathologic
Who are those affected by spondylolisthesis?
-Athletes in extension type sport (football, gymnastics, figure skating)
When do symptoms usually develop in spondylolisthesis?
Usually around a growth spurt
How does spondylolisthesis present clincially?
-Extension is worse
-Straight leg raise positive
Diagnosis of spondylolisthesis
-Need to order plain film oblique view!
-Scotty dog defect
Treatment of spondylolisthesis
-Rest and remove provoking activity
-Bracing only if severe
-Protocols for return to sport
Grading of spondylolisthesis
1 = 0-25%
2 = 25-50%
3 = 50-75%
4 = 75-100%
5 = 100+%
Lateral curve of the spine (at least 10 degrees) with a rotational deformity
What is the MC spinal deformity?
Define structural scoliosis
-Curve NOT reducible w/flexion or lateral flexion
Define non-strucutral scoliosis
-Fixed (curve NOT reducible)
-Non-fixed (curve reducible w/flexion or lat flexion)
Define functional scoliosis
-Curve able to be reduced partially or completely w/flexion or lateral flexion
Types of scoliosis
Causes of scoliosis
-Misc (tumor, abscess)
Types of idiopathic scoliosis
-Infantile (under 3 yo, majority resolve spontaneously)
-Juvenile (3-9 yo, high rate of progression and lead to severe deformity)
-Adolescent (80-90% of idiopathic cases, onset at puberty)
Describe adolescent idiopathic scoliosis
-Puberty (10-13 yo)
-Female 3.6 to male 1
Diagnosis of scoliosis
-Postural screen (look from posterior and lateral)
-Forward flexion test (look for rib hump)
Treatment of scoliosis curves greater than 20-25 degrees
May need bracing and exercise
Treatment of scoliosis curves greater than 45 degrees
Cannot be effectively braced
Treatment of scoliosis curves greater than 45-50 degrees
May need surgery
How often do we monitor younger patients w/scoliosis?
Every 4-6 months
Describe bracing in scoliosis
-Goal is to stop worsening curve
-Wear 23 hours a day (some just at night)
-May have to wear months to years
How does cervical myelopathy present?
Hyperreflexia of DTRs
Hoffman's sign (finger flexor reflex)
Most cervical spine fractures occur where?
C2 or C6-7
Most fatal cervical spine injuries occur where?
Jefferson fracture and types
-Posterior arch (MC)
Pedicle of C2 resulting from hyperextension injury
Cervical compression fracture types
I: simple wedge fx
III: comminuted burst body fx
IV and V: complex involving posterior elements