Back and Pelvic Disorders Flashcards
(57 cards)
1
Q
Common back complaint hx? How common of a visit is this?
A
- 2nd MC sx reason for provider visit
- hx of back, buttock, leg pain assoc w/ movement or positional changes
- may or may not recall a specific injury or mechanism
- acute, chronic or acute on chronic
2
Q
Lordosis?
Kyphosis?
Scoliosis?
A
- lordosis: increased anterior convexity in the curvature of the spine
- kyphosis: exaggeration of posterior convexity of the thoracic vertebral column found commonly w/ OA and osteoporosis
- scoliosis: lateral curve of the spine usually right convex thoracic, most of, which are idiopathic
3
Q
What is spondylolisthesis?
Stenosis?
Spondyloysis?
A
- spondylolithesis: anterior slip, bilateral pars defect, congenital usually L5 on S1, degenerative L4 on L5 - palpable step off w/ or w/o neurological sxs
- stenosis: narrowing of the spinal canal or neural foramen producing root ischemia or neurogenic claudication
- spondylolysis: stress fracture of pars interarticularis
4
Q
What should be included on your PE of LB?
A
- note curves of spine, posture, uneven ht of iliac crests
- ROM: flexion, extension, sidebend, rotation
- palpation of spinous processes: prominence especially of L4-L5 in relation to another indicates potential spondy
- paravertebral palpation
- LE ROM: decreased IR/ER or reproduction of pain may indicate hip jt pathology
5
Q
L4 testing?
A
reflex: patellar
- muscle test: ankle
- dorsiflexion = anterior tibialis
- sensory - medial foot and leg
6
Q
L1, L2, L3 testing?
A
- L1, L2, L3 no individual reflex, muscle and sensory testing only
- muscle test - hip flexion = iliopsoas
- sensory: area b/t inguinal ligament and above patellae
7
Q
L5 testing?
A
- reflex - none
- muscle test - great toe extension = extensor hallucus longus
- sensory-lateral leg and dorsum of foot
8
Q
S1 testing?
A
- reflex: achilles
- muscle test: ankle eversion = preens longus and brevis
- sensory: lateral foot
9
Q
Composition of discs?
A
- lumbar vertebrae are largest, and strongest
- interverteral disc lies b/t 2 adjacent vertebrae
- composed of nucleus pulposus (central gelitanous portion) enclosed in several layers of fibrocartilaginous laminae (annulus)
- fxn of disc is to provide cushion and facilitate movement in the spine
10
Q
Ligaments of the vertebrae?
A
- ALL: broad sheath of CT along w/ the anterior surface of vertebral bodies
- PLL: lies along posterior surface of vertebral bodies inside vertebral canal
- interspinous and suprapinous: connect spinous processes
11
Q
Musculature of the spine is innervated by?
A
- dorsal rami of spinal nerves and are enclosed by fascia
12
Q
Attachment of muscles and location of nerves in spine?
A
- muscles of spine attach to spinous and transverse processes
- superior and inferior articulating processes articulate w/ vertebrae above and below to create facet jt on either side of spine
- openings b/t 2 adjacent vertebrae is the intervertebral foramen which forms the spinal canal, the passage of spinal nerves occurs here
13
Q
Dx tests for spine disorders?
A
- plain radiographs: AP and lateral along w/ A/P pelvis and lateral hip on affected side. Visualize compression fractures, DDD, scoliosis, spondy, hip OA ex bondy deformities
- bone scan: r/o infection, occult met tumor
- Diskography: surgical purposes only: determines level of pain source
- CT myelogram: accurate assessment of stenosis
- MRI: most useful for disc injury, road map for surgery (only get contrast for: tumor, infection, recurrent disc herniation)
- labs: high risk pts (nursing home pts, poorly controlled diabetes, cancer pts) or unimproved after 8-12 wks of conservative tx. CBC and sed rate to r/o infection, tumor
- other dx tools for neurogenic pain: abdominal x-ray, CT
14
Q
What is a herniated disc? What can this cause?
A
- herniated disc fragment comes from nucleus pulposus of the disc
- in normal condition: nucleus is in disc center securely contained by annulus fibrosus
- when fragement of nucleus herniates, it irritates and/or compresses the adjacent nerve root
- this can cause pain syndrome known as sciatica and in severe cases, dysfxn of the nerve
- almost 5% of males and 2.5% of females experience sciatica at some time in their lifetime
15
Q
Sxs of a herniated disc?
A
- can or can’t be assoc w/ some degree of back pain
- pain usually radiates into leg
- may be characterized as less achy, burning or similar to an electrical shock and is often described as a shooting or stabbing pain
- level of leg pain/radiculitis usually depends on level of disc involvement
- L5-S1 which occurs MC, causes lateral and posterior thigh and leg pain
- the pain usually improves when the pt is in supine position w/ the knee bent
- numbness or tingling occurs with a distribution similar to the pain
16
Q
How will herniated disc present on exam?
A
- pts may be neurologically normal, or may have a profound radiculopathy
- a + straight leg raising sign is almost always present for lower levels. However a crossed straight-leg raising sign may be even more predictive of a lumbar disc herniation
- gait is often abnormal, muscle weakness may be revealed particularly when testing walking on heels and toes (may have foot drop: won’t be able to dorsiflex)
17
Q
Imaging for herniated discs?
A
- MRI is most useful, however far lateral recess disc herniation can be missed w/ MRI
18
Q
Tx for herniated discs? What pts are candidates for surgery?
A
- tx: consists of conservative care vs surgical management
- conservative care: consists ofPT in conjunction w/ NSAIDs or oral steroids, w/ muscle relaxants
- most cases will resolve w/ conservative tx, try to avoid prolonged narcotic, muscle relaxant or steroid use
- can use epidural steroid injections (helpful for herniated discs not general back pain)
surgical: need to have the right situations
- pt presenting w/ cauda equina syndrome or profound motor deficits
- a pt demonstrating progressive neurologic deficit during a period of observation
- a pt w/ persistent bothersome sciatic pain, despite conservative management, for a period of 6-12 wks
19
Q
What is spinal stenosis?
A
- spinal canal narrowing w/ possible subsequent neural compression
- facet hypertrophy of vertebra, vertebral body osteophytes, ligamentous flavum hypertrophy and disc degeneration
- narrowing is at disc space
- can be caused from secondary etiologies as well: neoplasm, acromegaly, pages disease, ankylosing spondylitis
20
Q
How will spinal stenosis manifest?
A
- bilateral neural claudication (NC)
- NC pain is exacerbated by standing erect and downhill ambulation and is alleviated w/ lying supine and forward flexion
- NC, unlike vascular claudication, isn’t exacerbated w/ biking, uphill ambulation, and lumbar flexion and isn’t alleviated w/ standing
21
Q
Exam findings of spinal stenosis?
A
- pain w/ extension that is relieved w/ flexion
- radiculopathy may be noted w/ motor, sensory, and/or reflex abnormalities
- other + findings would include loss of lumbar lordosis and forward flexed gait
22
Q
Studies and tx for spinal stenosis?
A
- imaging: basic radiographs
- MRI: imaging of choice
- vascular studies: if unsure or if confounding findings
- tx: PT stressing good spinal flexion, maintain fitness level
- surgery usually some form of laminectomy
23
Q
What is DDD? How will this present?
A
- disc dries out and loses shock absorption effect, physiologic event modified by trauma, hereditary, smoking, pain usually felt in lower backc and one or both buttocks. Mechanical activity will cause pain to increase
24
Q
Eval findings of DDD? Imaging?
A
- pain and decreased ROM w/ performing flexion and extension of spine in standing position. Normal neuro exam and SLR, not reproducible w/ hip rotations. Radiographs including AP and lateral lumbar spine indicate disc space narrowing at single or mult levels
25
Management of DDD?
- NSAID, back education program (PT), no narcotics, refer to MRI if sxs not controlled w/ above or if neuro sxs develop
26
What is facet syndrome?
- DJD of articulating surfaces of vertebrae. Similar findings of DDD. This is a radiographic dx. Tx is stats as above as is PE ( pain and decreased ROM w/ flexion and extension of spine in standing position, normal near exam, and SLR, not reproducible w/ hip rotations).
- tx: NSAIDs, PT, no narcotics, refer to MRI if sxs not controlled or if neuro sxs develop
27
Cause of muscle sprain? Eval, and management?
- caused by repetitive lifting, bending, or other trauma. Pain lasts days to weeks. Pain is usually localized w/o radicular sxs or neuro findings
- eval: normal neuro exam, specific muscular tenderness and reproducible pain w/ muscle testing or movement. Inflamed and swollen muscle. Radiographs are normal
- Management: NSAID, back ed pain, relative rest w/ activity modification. Refere if not better after 4-6 wks of adhering to above regimen
28
What is cauda equina syndrome? Eval, management?
- MOI: usually trauma, spinal cord injury, compression of sacral nerve roots
- MC cause: disc herniation
- urinary retention w/ neurogenic bladder (place a foley and pull - natural rxn should be sphincter contraction - but in cauda equina - reflex isn't intact)
- eval: rectal tone, bulbocavernosus reflex (pulling foley), S1, S2, S3, sacral sparing evaluating perianal sensation
- management: refer immediately, emergent
29
What is ankylosing spondylitis? Who does this affect MC?
- usually classified as chronic and progressive form of seronegative arthritis.
- has predilection for axial skeleton, affecting particularly the sacroiliac and spinal facet jts
- found in scandanavian pop
- formation of bony bridges b/t adjacent vertebrae, and progressive ossification of extraspinal jt capsules and ligaments
- this tissue replaces the disc fibers w/ new bone
- approx 90-95% of pts w/ AS have tissue ag HLA-B27, strong genetic influence exists, family hx common
- young males typically affected, peak: 15-35yo
30
Presentation of AS?
- MC presenting sx: low back pain
- pain is centered over sacrum and may radiate to groin and buttocks
- typical pt is a young man who has repeated episodes of back pain waking him up at night and assoc w/ spinal stiffness in the morning
- loss of lateral flexion of lumbar spine is earlies objective sign of spinal involvement
- chest expansion becomes restricted w/ involvement of costovertebral jts
- sacroiliitis may be detected by encountering a tenderness response during percussion over sacroiliac jts
31
Imaging and lab studies of AS? Tx?
- radiographs reveal bamboo spine, fused SI jts
- may have elevated sed rate w/ + HLA B-27
- tx: regular lifelong exercises are mainstay of tx program and NSAIDs
32
WHen do compression fractures occur? Shape of vertebrae?
- can occur w/ acute trauma, but most commonly in osteoporotic elderly pop
- MC compression fractures cause wedge shape of vertebrae
- can be severe resulting in burst fracture
33
Sxs of compression fracture?
- midline back pain hallmark sx of lumbar compression fractures
- pain is axial, nonradiating, aching or stabbing in quality and may be severe and disabling
- reports lower extremity weakness or numbness are impt signs of neuro injury from fracture
34
How are compression fractures dx?
- often when elderly pt presents w/ sxs such as progressive scoliosis or mechanical lower back pain and the clinician obtains routine lumbar radiographs
- often, compression fracture is presenting sx or finding that leads to dx of malignancy
- detailed neuro exam is essential, typically has kyphotic posture that can't be corrected. Kyphosis is caused by wedge shape of fracture, essentially turning squares to triangles
- palpation is impt to correlate any reports of pain to radiographic level of injury
35
Imaginga nd tx for compression fracture?
- imaging: AP/lateral radiographs
- MRI: can help determine an acute compression fracture from an old stable compression fracture
- tx: can be both conservative or surgical depending on amt of compression, and or any burst elements
- surgical intervention/referral if compression results in greater than 30% of vertebral ht and is assoc w/ significant pain
- conservative tx consists of bracing, analgesic meds, and rest
36
Scoliosis -
| What is it, and what is the cause?
- 3d prob not just 2d
- cause has been postulated to be genetic in nature
- causes lateral curvature of spine, greater than 10 degrees away from central axis
- curve is found w/o presenting pain, rarely if ever painful
37
Testing and presentation for scoliosis?
- foward flexion test
- high sided scapula/shoulder
- MC curve is right thoracic
38
Tx indications for scoliosis?
- curves less than 25 degrees, observe w/ serial x-rays overtime
- bracing for rapidly progressing curves to 20-25 degrees or greater
- bracing for curves 20-40 degrees
- surgical tx for inflexible curves over 40 degrees and essentially any curve over 50 degrees
- cobb angle: measure of resulting scoliosis angle based on radiographs
39
How does LBP usually present?
- local pain, acute often recurrent or chronic aching pain in L-S region possible radiating to butt not below knees. Pain often precipitated or aggravated by moving, lifting or twisting motions and relieved by rest, spinal movements typically limited by pain
40
How does radicular pain usually present (ex. sciatica)?
- nerve root pain usually superimposed on LBP. Sciatic pain is shooting and radiates down 1 o both legs usually below knee or knees in dermatomal distribution often w/ assoc numbness and tingling possible local weakness
- pain usually worsened by spinal movements such as forward flexion, sneeze, cough or strain
41
How does referred pain usually present?
- usually deep aching pain level of which varies w/ source. Spinal movements aren't painful and ROM doesn't reproduce pain. Look for signs of primary disorder (PUD, pancreatitis, prostatitis, bladder infection, endometriosis, AAA). This involves much more complete exam including CVA, pelvic, urine dip, abdominal and cardiac exam, prostate and rectal exam
42
What should you consider w/ nocturnal aching back pain unrelieved by rest?
- if pt presents w/ local bone tenderness:
- consider met malignancy in spine from prostate, bladder, kidney, breast, lung
- this requires thorough hx and physical pain
43
How will facet syndrome present?
- local paralumbar pain or tenderness from forceful extension-rotation injury, pain aggravated by extension, nonradiating pain or pain referred to butt and thigh, confirmation by fluoroscopic facet injection
44
Presentation of spondylolysis?
- repetitive hyperextension injury: pain worse w/ extension and relieved by flexion, bone scan and SPECT positive
45
Presentation of spondylolisthesis?
- bilateral pars defects, usually L5-S1, palpable step off w/ or w/ o neuro sxs
46
How will anterior compression fracture present?
- severe acute thoracic pain, fall from ht in young pt, osteoporosis in older pt
47
Cause of spinous or transverse process fracture?
- direct blow
48
Presentation of sacral stress fracture?
- lumbosacral pain, usually in long distance runners
49
Presentation of central canal stenosis?
- older than 55, back and butt pain exacerbated by walking or standing and relieved by sittting or flexion, radiating pain, numbness or weakness to lower extremities
50
How does rheum disease present (AS, reiter's, psoriatic arthritis)?
- younger male, lumbosacral pain, morning stiffness, improvement w/ activity, radiographic sacrolitis, elevated ESR and CRP
51
How does Scheuermann's disease present?
- adolescent, thoracic or thoracolumbar pain, increased thoracic kyphosis, wedging of 3 or more contingous vertebrae w/ end-plate irregularities (schmorl's nodes)
52
Presentation of diskitis?
- onset of severe low back pain, fever, malaise, and irritability, refusal to sit, walk, or move, elevated ESR, CRP, and WBC count
- osteomyelitis presents similar but in older pop
53
Endometriosis presentation?
- 15-45, cyclic back pain, pelvic pain
54
Diff sacroiliac jt pain from prostatitis?
- male older than 30, dysuria, back and perineal pain, lumbosacral pain w/ radiation to butt, groin, or thigh, SIJ tenderness, confirmation by fluoroscopic SIJ injection
55
Possible causes of chronic persistent low back stiffness?
- AS (common in young men) - loss of normal lumbar lordosis, muscle spasm, and limitation of anterior and lateral flexion
- diffuse idiopathic skeletal hyperostosis (DISH), which affects middle aged and older men - flexion and immobility of spine
56
Possible etiologies of back pain referred from abdomen or pelvis?
- usually a dull aching pain, level of which varies w/ source
- peptic ulcer, pancreatitis, pancreatic cancer, chronic prostatitis, endometriosis, dissected aortic aneurysm, retroperitoneal tumor
- physical signs: spinal movements not painful, and ROM isn't affected, look for signs of primary disorder
57
What are S/S of life threatening proportion?
- aching nocturnal pain unrelieved by rest
- S/S AAA
- B/B incontinence
- cauda equina
- spine fracture w/ instability (shifted spine)
