Clinical Correlations: Spine and Back 9/24 Flashcards Preview

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Flashcards in Clinical Correlations: Spine and Back 9/24 Deck (23):
1

Scoliosis

- most common deformity, affects pre-pubescent girls most

Causes: 

  • idiopathic (genetic ~80%)
  • congenital: hemivertebrae
  • shorter leg
  • spina bifida, MD or osteoporsis

- primary curve (i.e due to shorter leg- spine bends towards longer leg)

- secondary curve (compensatory)

- spinous processes rotate toward the

- harrington rods used to reduce this

2

Compression Fractures

- can be due to traumatic load bearing (i.e. diving and head contacting ground) or can be pathological. 

--> osteoporotic: weaked bony trabeculae coupled with reduced thickness of cortiacl bone --> compression of vertebral bodies  (when lose density, vertebrae become wedge shaped and it increases kyphotic curve)

--> neoplastic : metastasis from prostate/breast/ovary/hodgkin's lymphoma to vertebral bodies via basivertebral veins of Batson's plexus --> tumors errode trabeculae

3

Dislocation/Fracture Dislocation of Cervical Vertebrae

- due to the disposition of the articular facets as well as the reduced mass of the region, the ervical vertebrae are more subject to dislocation when compared to other areas of the spinal column

- Specific dislocations/fractures: Jefferson Burst (atlas), hangman's (axis), dens fracture, rupture of the transverse ligament of the atlas, rupture of the alar ligaments

4

Jefferson Burst

Fracture to the arches of the atlas due to excessive force to the crown of the skull, forcing the lateral masses of the atlas laterally 

- this would be further complicated by the rupture of the transverse ligament of the atlas

- because there is no body here, the burst occurs in the anterior and posterior arch of fracture

5

Hangman's Fracture

- forceful hyperextension of the head on the neck caues bilateralfracture through the pars interartiuclaris 

6

Fracture of odontoid process

- "dens" fracture

- may fracture from the body of CV2 completely or fracture with a part of it

 - disarticulation of dens = complete fracture ---> avascular necrosis (dens dies b/c no blood supply) --> results in atlas moving in A-P direction and impinging on nerve similar to the rupture of the transverse ligament- though not as severe because it is not pushedd against the dens

- with transverse ligament of the atlas intact, dens and anterior arch of the atlas remain attached 

- disar

7

rupture of the transverse ligament of the atlas

- this allows the atlas to move freely (atlanto-axial subluxation) in an A-P direction relative to the axis allowing the spinal cord to be piched between the body and the dens of the axisand the posterior arch of the atlas. 

- can result in quadraplegia or death

- NOTE: this ligament is lax or missing in down's syndorme which increases their susceptibility to atlanto-axial sublation

8

rupture of alar ligaments

- allows for increased rotation of the skull and CV1 on CV2 (~30 degrees more)

- cause: increased flexion with rotation of the skull (flexion limits the rotation of the atlas on the axis and places increased  stress on the alar ligaments)

9

Spondylolysis

- a condition whose defect (can be trauma induced) exists in the pars interacticularis of the neural arch between superior and inferior articulating processes

10

Spondylolisthesis

- (bilateral spondylolysis)- located at one vertebral segement allows that vertebral body as well as the entire spinal column above, to slide forward on the vertebra below. the most common site for this to occus is LV5 on SV1. 

- scotty dogs

- in lumbar region, breaks closer to lamina

- in cervical region, breaks closer to pedicle

11

spina bifida occulta

- least serious type of spina bifida

- neural arch defect at LV5 or SV1 (affects 25% of population)

- may be complete or partial; usually spinous process is absent because lamina don't fuse properly

- tuft of hair located here

12

spinal involvement of osteoarthritis

- results in spondylosis: narrowing of the IV foramen - pinching of nerves

- this is degenerative change involving the vertebral body adn adjacent IV disk. With increased age, the water contect of cartilage that covers the articular surfaces of the vertebral bodies increase while protein decreases. 

- degeneration of articular cartilage leads to inflammation and osteophyte (bone spur) formation

- with increased degen. of articular cartilage, disk space narrows. Coupled with osteophyte formation, IV foramina become narrowed (spinal stenosis) and spinal nerves may be impinged, leading to radiculopathy (pain districuted along the path of a dermatome)

- Following procedures to relieve symptoms of radiculopathy associated with stenosis

  • laminectomy: surgical removal of a spinal process and the adjacent lamina to gain access to the spinal canal for purpose of relieve pressure like osteophytic growht
  • - faoraminotomy - surgican enlargement of hte IV foramen to relieve pressure placed on spinal nerves

13

spinal stenosis

- narrowing of IV foramina (can be seen in osteoarthritis)

14

Osteoarthritis of zygapophyseal (facet) joints

- same pathophysiology as spondylosis

- can affect all facet joints of the spine

- leads to further narrowing of the IV foramina

NOTE: aside from the radicular pain theat emanates from nerve root impinement, articular pain fibers also exist which respond to a high degree due to the inflammation of hte joint

15

whip lash injury

- rapid hyperextensionof the spinal column can rupture the anterior longitudinal spinal element and may even avulse a portion of the anterior surface of the vertebral body at the point at which the ligament ruptures

16

Ankylosing Spondylitis

- ultimately results in ossification of annulus fibrosus of IV disks, apopphyseal joints, and anterior longitudinal and interspinal elements --> results in fusion of joints/ligament --> results in a fused spine

Progression of the DIsease: 

  1. Inflammation of sacroilial and spinal elements
  2. ostephytic bone growth into ligaments
  3. fusion of the spine

- makes arms swing/normal gait impossible

- occurs most often in men in 3rd/4th decade

- genetic mutation in protein HLA B-27

- radiological mark is "bamboo spine" 

17

Ruptured disk

- tearing of the annulus fibrosus WITHOUT protrusion of the nucleus pulposus

 

18

Herniated Disk

- tearing of the annulus fibrosus WITH protrusion of the nucleus pulposus (this happens more in areas of greater mobility - cervical and lumbar)

- usually due to suddent and violent hyperflexion of spine. 

- IV disk becomes comppr=ressed anteriorly and stretched posteriorly

- if the annulus tears, the nucleus can herniate posteriorly into the spinal canal

*** Most herniations occur posteriolaterally (directed by the posterior longitudinal ligament) --> impinges on roots of spinal nerves. Most occur in L4-L5, L5-S1 reion where disks are largest and weight born e is the greatest movement in the plane of flexion and extension. 

NOTE: pain that is easily localized is acute pain and results from the actual tear of the annulus, regional inflamation as a result of the herniated nucleus and pressure placed on the posterior longitudinal ligament via the bulgin disk. ..... Chronic pain associated with herniation is due to compression of the spinal nerve root resulting in a continual low grade depolarization that results int he patient "feeling" pain int eh receptive field of the compressed nerve. 

NOTE: herniations that occur int eh cervical region affect spinal nerves at the same level as the herniation. herniations that occur in lumbar regions, due to the angle at which the spinal nerves descend fromt he spinal cord relative to the herniated IV disk affect the spinal nerve one or more segments below. 

19

stages of IV disk herniation

  1. disc degeneration: chemical changes associated with aging cause disks to weaken, but without herniation
  2. prolapse: the form or position of the disc changes with some slight impingement into the spinal cord (bulge/protrusion)
  3. extrusion: the gel-like nucleus pulposus breaks through the annulus fibrosus but remains within the disk
  4. sequestered disc: the nucleus pulposus breaks through the annulus fibrosus and lies outside the disk in the spinal cord

20

Ischemic Paralysis of the Spinal Cord

- Anterior and Posterior spinal arteries run the full length of the spinal fcord

- without ramification via spinal and radicular branches of segmental arteries (branches of arteries which parallel the spinal column and send branches into the IV foramen to supply the spinal column, spinal nerve roots, and spinal cord) the anterior and posterior spinal arteries would not be patent in their entire length

- interference in the supply of blood provided by the segmental arteries due to trauma, cross-clamping the aorta or aortic aneurysm can lead to ischemia of the spinal cord --> paresthesia or paraplegia in the area affected by the ischemia

21

Lumbar Puncture

- "spinal tap" 

  • removal of CSF from subarachnoid space via a needle which passes between contiguous protions of the ligamentum flavum 
  • patient flexes spine to increase distance between lumbar laminae
  • needle passes through the dura and arachnoic mater to remove frluid from the subarachnoid space

- in adult, LP proceeds in midline between LV3/4 or LV4/5 as the spinal cord ends at the L1/2 interspace. in children care must be taken as cord ends at L4/5. 

22

Caudal Epidural Anesthesia

- needle passed through the sacral hiatus and into the sacran canal to deliver anesthesia to the surface of the cauda equina

- used to deliver "saddle" block type of anesthesia for child birth; relieves pelvic pain without removing motor control which originates at higher spinal levels 

23

tension headaches

- greater occipital nerve is trapped in deep back muscles of the semispinalis capitis. When this is continually tensed it triggers pain fibers that extend to the vertex of the skull