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Clin Med II - Ortho > CSP/TSP > Flashcards

CSP/TSP Flashcards

1
Q

C1

A

The atlas

Has no vertebral body and no spinous process

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2
Q

Occiput-C1 articulation

A

Two superior concave facets that articulate with the occipital condyles (hold the skull)
3 ligaments provide stability
- Transverse
- Alar
- Apical
Makes up 50% of neck flexion and extension

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3
Q

C2

A

The Axis

Has odontoid process (dens) and body

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4
Q

C1-C2 (atlantoaxial) articulation

A

Diarthrodial joint that provides
50° (of 100) cervical rotation
10° (of 110) of flexion/extension
0° (of 68) of lateral bend

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5
Q

C1 to C7

A

Have a transverse foramen

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6
Q

C2 to C6

A

Have bifid spinous process

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7
Q

Curve of the cervical spine

A

Lordotic curve

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8
Q

Cervical ligaments - in general

A

Ligamentum flavum
PLL
ALL

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9
Q

Ligamentum flavum

A

Covers the dura

Connects under the facet joints to create a small curtain over the posterior openings between the vertebrae

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10
Q

PLL

A

Runs up and down behind the spine

Inside the spinal canal

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11
Q

ALL

A

On the front side of the vertebrae

Firmly unites with periosteum and annulus

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12
Q

Intervertebral discs

A

Accounts for 25% of spine height
Not present at C1-C2
Annulus fibrosus
Nucleus pulposus

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13
Q

Annulus fibrosus

A

Outer structure that encases the nucleus pulposus
Characterized by high tensile strength and its ability to prevent inervetebral distraction
Remain flexible enough to allow for motion

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14
Q

Nucleus pulposus

A

Central portion of the intervertebral disc composed of gel and approx. 88% water
Responsible for height of the intervertebral disc
Resist compression and distributes forces evenly to endplates of vertebrae

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15
Q

Nerve roots

A

Exit above corresponding pedicle through foramen (below in the TSP and LSP)
Travels horizontally to exit (in contrast to lumbar that descends before it exits)
There is an extra C8 nerve root that does not have a corresponding vertebral body

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16
Q

Exam - Inspection

A 
Alignment in sagittal and coronal plane
Skin defects 
Muscle atrophy
Prior sx scars
Fasiculations / tremors
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17
Q

Exam - Palpation

A

Know your landmarks

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18
Q

Exam - ROM

A

May document absolute degrees or relative to anatomic landmark (eg chin rotates to right shoulder)

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19
Q

Normal ROM of CSP

A

Flexion - 50
Extension - 60
Rotation - 80
Lateral bend - 45

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20
Q

Exam - Sensory

A

Document sensation to all dermatomes
Perform light touch in all pts - stroke lightly with finger
If a deficit, proceed with other sensory types
- pain
- vibration
- temperature
- two point discrimination

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21
Q

Motor

A 
C5: Deltoid - Shoulder abduction
C6: Biceps - Elbow flexion
C6: ECR - Wrist extension
C7: Triceps - Elbow extension
C7: FCR - Wrist flexion
C8: FDP - Flexion middle finger
T1 - Hand interossei - spread fingers
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22
Q

Muscle grading system

A

1 - muscle contraction is visible but there is not movement to the joint
2 - active joint movement is possible with gravity eliminated
3 - Movement can overcome gravity but not resistance from the examiner
4 - The muscle group can overcome gravity and move against some resistance from the examiner
5 - Full and normal power against resistance

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23
Q

Reflexes

A

Biceps - C5, C6
Brachioradilais - C5, C6
Triceps - C7

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24
Q

Congenital Torticollis - in general

A

Most common position is lateral flexion and rotation
Rare - <2% incidence
May accompany clavicular fx, esp. in neonates
Up to 20% of children with congenital muscular torticollis have congenital hip dysplasia as well

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25
Congenital Torticollis - causes
Birth trauma to the SCM M., results in fibrosis or compartment syndrome Intrauterine malpositioning leads to unilateral shortening of SCM May be associated with SCM tumor, called fibromatosis colli Often have undergone breech or difficult forceps delivery
26
Congenital Torticollis - dx
Clinical | If refractive to tx or palpable mass, do neck US and CSP x-ray
27
Congenital Torticollis - Tx
PT Home exercise program positioning Botox or sx for severe refractive cases >6-12m duration
28
Torticollis - in general
Common term for cervical dystonia | May also be static or a dynamic tremor
29
Torticollis - causes
Idiopathic Inherited due to genetic mutation Acquired - infection, vascular abnormality, brain injury, toxins Drug exposure (levodopa, dopamine agonists, antipsychotic drugs, anticonvulsants, SSRIs, metoclopramide Reglan) Neurological - CP, Huntington dz, Parkinson's Psychogenic
30
Torticollis - dx
Clinical but workup for cause
31
Torticollis - tx
Tx cause PT Botox - type A
32
Cervical Strain / Sprain - in general
The result of a stretch injury to the soft tissue elements of the CSP
33
Strain
Muscle or tendon
34
Sprain
Ligament
35
Cervical Strain / Sprain - causes
Acute - whiplash Repetitive / chronic Abnormal posture - carrying a heavy suitcase on one side of the body, computer work, weak core
36
Cervical Strain / Sprain - presentation
``` Axial pain Stiffness Muscle spasms Ha Neck fatigue ```
37
Cervical Strain / Sprain - exam
Tenderness with palpation Painful +/- decreased ROM No radicular signs
38
Cervical Strain / Sprain - imaging
XR +/- MRI
39
Cervical Strain / Sprain - Tx
Cervical collar is as short term tx - 1-2 wks | Modalities: ice, heat massage, topical analgesics, PT
40
Disc Herniation - in general
Most common is C5-6 and C6-7 Disc may compress either the SC or the exiting nerves or both Pressure on an exiting cervical nerve root can cause changes in sensory, motor and/or reflex function in the innervated areas (radiculopathy)
41
Disc Herniation - exam
Weakness Decreased sensation Asymmetric reflexes Special tests
42
Spurling's test
Perform if you suspect nerve root compression Place pt in slight extension & lateral flexion. Apply axial force Closes the neuroforaminal space Positive if pain in a radicular, dermatomal pattern on ipsilateral side Specific, but not sensitive, in dx acute radiculopathy
43
Distraction test
``` Used when currently symptomatic Relieves symptoms Supine or sitting - place hands at occiputs and apply gentle distraction Positive if reduces symptoms Indicated a neuroforaminal compression ```
44
Disc Herniation - imaging
XR MRI - test of choice CT/Myelogram
45
Disc Herniation - tx
Nearly 90% can be tx conservatively - PT, rest, modalities, NSAIDs, oral steroids, CESI
46
Disc Herniation - sx
Pain management has failed Intractable upper limb with imaging evidence of a correlating nerve root compression Mechanical instability of the spine associated with disc herniation S/s of neurological deficits are increasing The disc herniation is massive and compresses the SC (myelopathy)
47
Myelopathy - in general
SC compression
48
Myelopathy - causes
``` Trauma Infection Inflammatory or autoimmune d/o Tumor Degenerative spondylosis Disc herniation ```
49
Myelopathy - presentation
``` Myelopathic or "upper motor neuron" findings Hyperreflexia Tremor Loss of fine motor control Babinski's Hoffman's Spasticity Ankle clonus Often painless May present with difficulty walking Coordination issues Incontinence or retention Loss of fine motor control ```
50
Hoffman's sign
Hold and secure the middle phalanx of the long finger and then flick the distal phalanx Positive is involuntary contraction of the thumb and index finger IP joints
51
Ankle clonus test
Rapidly flex the foot into dorsiflexion (upward), inducing a stretch to the gastrocnemius M. Positive is tapping of the foot. Only a sustained clonus (5 beats or more) is considered abnormal
52
Babinski reflex
Lateral side of the sole of the foot is rubbed with a blunt instrument or device from the heel along a curve to the metatarsal pads Positive is when the hallux dorsiflexes and the other toes fan out
53
Myelopathy - imaging
MRI - preferred | CT/Myelogram, if MRI is CI
54
Myelopathy - tx
Involves decompressing the SC through various procedures depending on cause, spinal level and each pt
55
Sponylosis - causes
Dehydrated, shrinking discs Aged herniated/cracking disc Osteophyte formation Contractures of ligaments and joint capsules
56
Sponylosis - in general
Degenerative condition Typically begins to be seen at 40-50yo M>W Most commonly occurs at C5-6 > C6-7 levels
57
Sponylosis - RF
Frequent lifting Smoking Driving
58
Sponylosis - chronic changes
May lead to - Radiculopathy - Myelopathy - Both
59
Sponylosis - tx
Symptom management - PT - Pain clinic - NSAIDs
60
Odontoid fx - imaging
Seen on open mouth odontoid view XR CT best next test for fx and stability eval MRI if neurological symptoms exist
61
Odontoid fx - types
1 - avulsion of tip, rarely neurological s/s, usually stable - brace 2 - the waist , high non-union rate - halo or sx 3 - involves the body of C2 - brace
62
Hangman's fx - in general
Fx of the pars interarticularis on the pedicle of the C2 verebrae Most common of all CSP fx Extreme hyperextension to the neck - MVA May result in spondylolisthesis-slipping of C2 on C3
63
Hangman's fx - imaging
Get CT to check for instability
64
Hangman's fx - tx
Immobilization for 4-6 wks, if no displacement vs. sx
65
Burst fx - in general
Fall from a height, landing on one's feet Compressive failure of vertebral body Most common at throacolumbar junction (T10-L2) Less common in proximal TSP b/c the ribs help to stabilize TSP canal is narrow in relation to the SC, so that thoracic SC injuries commonly are complete
66
Jefferson fx
Burst fx of C1 | Diving accidents
67
Chance fx - in general
A flexion-distraction injury - lapbelt injury Most commonly at the thoracolumbar junction 50% includ abdominal injuries
68
Burst fx - imaging
XR - AP, lat, obliques MRI - important to eval for injury to the posterior elements CT - important to eval degree of bone injury and retropulsion of posterior wall into canal
69
Columns of spine
Anterior column Middle column Posterior column
70
Anterior column
ALL Anterior 2/3 of the vertebral body Anterior 2/3 of the intervertebral disc
71
Middle column
Posterior 1/3 of the vertebral body Posterior 1/3 of the intervertebral disc PLL
72
Posterior Column
``` Everything posterior to the PLL Pedicles Facet joints and articular processes Ligamentum flavum Neural arch and interconnecting ligaments ```
73
Chance fx - tx (non-operative)
Immobilization in TLSO Neurlogically intact pts stable injury patterns with intact posterior elements <50% vertebral height is lost Minimal comminution Must be followed for non-union and kyphotic deformity
74
Chance fx - tx (operative)
Sx decompression and stabilization | Hx three level above and two level below but modern pedicle screws have changed this to allow fewer levels
75
Compression Fx - in general
Osteoporosis is the most common cause Estimated to affect 1/4 of all postmenopausal women in the US W>M People who have sustained one osteoporotic VCF have x5 risk of sustaining a 2nd one Mets tumor for MM should be considered in pts <55 with no hx of trauma
76
Compression Fx - presentation
May be asymptomatic and incidentally found on XR Present with midline back pain May radiate to ribs Typically neuro intact
77
Compression Fx - imaging
XR - dx the fx | MRI or bone scan confirms the acuity
78
Compression Fx - tx
Tx the osteoporosis Conservative at least 2 week before considering sx Kyphoplasty or verebroplasty with bx for failure
79
Thoracic Outlet Syndrome
Poorly categorized symptoms - vary Similar s/s to other neuro or vascular condition like - CTS - Ulnar neuropathy (cubital tunnel syndrome) - Cervical radiculopathy - Brachial plexus injuries - Myelopathy
80
Types of Thoracic Outlet Syndrome
Neurogenic | Vascular
81
Neurogenic Thoracic Outlet Syndrome - in general
Compression of lower brachial plexus, usally by tissue band that connects C7 to first rib Most common type - 95% W>M Often mis-dx early on
82
Neurogenic Thoracic Outlet Syndrome
``` May present with Anterior shoulder pain Clavicular pain N/T in arm Weakness Angina May be asymptomatc at rest ```
83
Neurogenic Thoracic Outlet Syndrome - imaging
CXR / Clavicle XR to r/o cervical rib
84
Cervical rib
An extra rib Present in <1% of population May be normal bone structure or undeveloped fibrous tissue
85
Vascular Thoracic Outlet Syndrome - in general
If the subclavian A. is compressed, pts may notice color changes, claudication or a vague pain in the arm or hand If the subclavian vein is compressed, there may be swelling of the arm, distension of the veins or a diffuse pain in the arm or hand Makes the referral urgent as this may be thrombus Pure TOS types aer rare and pts often present with s/s indicative of more than one type
86
Vascular Thoracic Outlet Syndrome - RF
``` Poor posture Hx of chest or clavicle trauma Kyphosis Large breasts Overhead athletes / workers ```
87
Vascular Thoracic Outlet Syndrome - exam
Work-up of CSP and shoulder are normal
88
Vascular Thoracic Outlet Syndrome - imaging
MRI of brachial plexus, NCS/EMG and doppler with angiogram is suspect vascular
89
Vascular Thoracic Outlet Syndrome - tx
PT/OT can help restore postural imbalances | Refer to ortho or CT surgeon
90
Adson test
A provocative test by compression of the subclavian A. by a cervical rib or tightened anterior and middle scalene M. Passively extend, abduct and externally rotate affected arm while palpating the radial pulse Ask pt to take a deep breath and hold it in Ask pt to extend neck and rotate the head towards affected side Positive if loss of radial pulse
91
Roos or East test
Have pt sit up with good posture Shoulders abducted to 90° and externally rotated Open and close fist for 1 min Positive if reproduction of s/s

Clin Med II - Ortho (13 decks)

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