Flashcards in Disorders of the Spine Deck (95):
What are the causes of low back pain?
1. Most Common: Mechanical LBP / Lumbosacral strain (lumbago)
A. Frequent cause of time lost and disability in adults < 45 yo
2. Prolapsed intervertebral disc, aka Herniated nucleus pulposus (HNP)
3. Degenerative disc disease (DDD)
4. Back pain can also be referred pain from:
Abdomen, pelvis or retroperitoneum
What questions need to be asked in the HPI for low back pain?
1. PAIN- PQRST
2. Is there hx of injury/trauma?
3. Pain at rest or activity-related?
4. Pain at night or not relieved w/ rest?
5. Is there evidence of systemic disease?
6. Is there evidence of neurologic compromise?
7. Is there bladder or bowel dysfunction?
8. Is there social or psychological distress that may contribute to chronic, disabling pain?
9. Prior injury?
What are the PE components for low back pain?
1. Inspection of back and posture (must be in gown)
3. Range of motion
4. Palpation of the spine and paraspinal muscles
5. Straight leg raising (SLR)
6. Neurologic assessment of L3-S1 nerve roots
7. Evaluation for malignancy (breast, prostate, lymph node exam)
A. when persistent pain or history strongly suggests systemic disease
What are the DDx for low back pain?
1, Mechanical low back pain
A. Strain, spondylolithesis, herniated disc, spinal stenosis, fractures, osteoporosis, congenital disease
2. Non Mechanical Spine disease
A. MM, metastatic carcinoma, lymphoma, spinal cord tumors, Infection, inflammatory arthritis, Paget's disease
3. Viseral disease
A. Prostatitis, endometriosis, CPID, renal disease, AAA, GI disease
What are the sxs of musculoskeletal pain?
1. Localized pain
2. Inc pain w/ movement
3. May have history of an injury
What are the sxs of Nerve root irritation aka lumbar radiculitis or radiculopathy?
1. Paresthesias and pain in specific dermatome
2. Pos. SLR btw 10-70 deg elevation, +/- contralateral SLR
What are the sxs of sciatica?
1. Burning pain felt along distribution of nerve
buttock, post. thigh, postero-lateral aspect of leg, lateral dorsum of foot
A. +/- positive SLR
What are the sxs of a lumbar radiculopathy?
Inc sxs w/
What are sxs for sciatica due to disc herniation?
Inc sxs w/
What dx studies are used for low back pain?
1. Xray: Not always necessary in first 4-6 wks of onset except w/ red flag signs & sxs
3. Spine CT scan
When is an MRI indicated for low back pain?
Suspicion of Spinal cord pathology, neural tumors, herniated discs and infections
Order when neural deficits are presetn
What does a spine CT scan show?
Identifies nerve entrapment & bony stenosis
What are the history red flags for low back pain?
2. Unexplained wt loss or loss of appetite
3. Recent fever, chills or infection
5. Pain @ rest or during Night
7. Recent onset of bowel or bladder dysfunction (incontinence or dysuria)
What are the PE red flags for low back pain?
1. Progressive neuro deficit in lower ext.
2. Saddle anesthesia
3. Loss of anal sphincter tone
5. Any child or adolescent with low back pain
What nerve root controls dorsiflexion?
What is the treatment for Low back pain?
1. NSAIDs +/- analgesics (2 wks for narcotics)
2. Postural exercises / PT
A. Extension exercises, avoid flexion
B. Encourage mobility and activity (Not bed rest)
3. Conservative treatment x 4-6 weeks
4. If no improvement after 4-6 weeks, check imaging studies & labs to r/o spinal cord tumor or infection
A. CBC w/ diff, CMP, Spep (looking for IgG
5. When conservative treatment fails, refer to Ortho for surgical consult
Define Herniated Nucleus Propulsus (HNP)
1. aka “slipped disc” or herniated disc
A. Occurs when all or part of nucleus pulposus (soft gelatinous central portion of intervertebral disc) protrudes thru annulus fibrosis (disc’s outer ring)
Who is HNP common in?
Middle-aged and older men more commonly
What is the etioogy of HNP?
1. Severe trauma or strain
A. Moving furniture
B. Lifting heavy box
2. Intervertebral disc degeneration
A. In older patients w/ degenerative disc disease, even minor trauma can cause disc herniation
What is the pathophys of HNP?
Physical stress, usually twisting motion, can tear/rupture annulus fibrosus -> herniation of nucleus propulsus into spinal canal-> compressing nerve root and/or spinal cord
What are the sxs of HNP?
1. Severe LBP radiating to buttocks, leg and/or feet
A. Worse with coughing, sneezing and valsalva
2. Sensory and motor loss in areas innervated by compressed spinal nerve root
What nerve controls extension of the quads?
What nerve controls dorsiflexion of the great toe and foot?
What nerve controls plantar flexion of the great toe and foot?
If the knee jerk reflex is diminished, what nerve is affected?
If the ankle jerk reflex is diminished, what nerve is affected?
How is L4 pathology screened?
Squat and rise
How is L5 pathology screened?
How is S1 pathology screened?
What nerve roots and nerves are associated with Hip flexion?
L2-3, Femoral nerve
What nerve roots and nerves are associated with knee extension?
What nerve roots and nerves are associated with ankle dorsiflexion?
What nerve roots and nerves are associated with hip extension?
What nerve roots and nerves are associated with knee flexion?
What nerve roots and nerves are associated with ankle plantar flexion?
What reflex is associated with L5?
What is the imaging study of choice for a herniated disc?
A. Imaging study of choice
shows herniated disc and if spinal cord compression present
2. Will have performed an Xray first
What structure do the nerve roots pass through to exit the spinal column?
What is the treatment for HNP?
1. Conservative Tx* (90% of pts recover with conservative tx)
A. First 24-48 ice, then heat
C. MacKenzie exercises / PT
D. Muscle relaxants
-Cyclobenzaprine (Flexeril) 10 mg po q 8h
2. If conservative treatment fails
A. Ortho Spine Referral
-Micro-discectomy and/or laminectomy
+/- Spinal fusion to stabilize spine
What is Malingering?How is it tested?
1. Falsely exaggerating or faking back pain: superficial non-anatomic tenderness, may express overreaction to physical examination testin
2. Waddel's tests
What are the Waddell's tests?
1. Non-physiologic exam
A. Non-dermatomal sensory loss
B. Cogwheel or give-way weakness
2. SLR testing discrepancy
A. Supine and sitting exam are not consistent
B. Sitting test (Flip test) performed while distracting pt
3. Pain on simulated maneuvers
A. Axial loading of skull
B. Pain on PROM of shoulders and pelvis
4. Positive if 3 criteria present
When do you suspect malingering?
Suspect malingering when pain is out of proportion to injury
What are the etiologies of cervical neck pain?
1. Cervical strain
2. DDD cervical spine
3. Whiplash injury
A. abrupt flexion/extension
4. Cervical radiculopathy
5. Brachial plexus injury
How may cervical radiculopathy present?
May present w/ shoulder pain and/or arm pain that is stemming from neck etiology
How may brachial plexus injury present?
1. Can include neck, arm, shoulder, finger and/or chest pain, weakness UE w/ numbness
2. Often misdiagnosed as cervical radiculopathy
What are the sxs of cervical neck pain?
1. Pain- PQRST acute or chronic
A. Nerve root?
B. C7 nerve root most common (C6-C7 level), then C6 nerve root (C5-C6 level)
3. Extremity weakness
4. Hx of trauma or MVA
What are the components of a PE for cervical neck pathology?
1. Neck ROM
2. Bilateral Shoulder ROM
3. Upper extremity strength and sensation testing
6. Shoulder abduction relief test
A. Positive when dec or disappearance of radicular sxs
7. Spurling’s maneuver
Neck compression test: + test if radicular pain or paresthesias occur
What are the red flags for cervical neck pain?
1. Fever, chills, unexplained wt loss
2. Difficulty walking, weakness in legs
3. Lhermitte’s sign
What is Lhermitte's sign?
1. Shock-like paresthesia occurring w/ neck flexion
2. Compression of spinal cord / nerve root in neck, cervical HNP or cervical spondylosis
3. often present in MS pts
What nerve root is the biceps reflex asst. with?
What nerve root are the biceps/brachioradialis reflex asst. with?
What nerve roots is the triceps reflex asst. with?
What dx studies are used for cervical neck pain?
1. Cervical x-rays
A. AP & lateral
A. If suspect HNP, r/o malignancy
3. NCS/EMG: order when you can't determine etiology of cervical pathology
How is cervical neck pain managed?
1. NSAIDs +/- analgesics (2 wks w/ narcotics)
2. Physical Therapy
A. Supine cervical traction
B. Neck strengthening exercises
3. Cervical pillow
4. If above fails
A. Epidural nerve block
5. Refer to Ortho or Neurosurgery
A. Anterior cervical discectomy and fusion (ACDF)
1. Lateral curvature of thoracic, lumbar or thoracolumbar spine
2. Curve may be:
A. Convex to right – most common thoracic
-Right thoracic curve @ T7 or T8 most common
B. Convex to left – more common lumbar
What are the rf for scoliosis?
A. Girls between onset of puberty and cessation spinal growth are at greatest risk
What is the etiology of scoliosis?
A. Most common type
A. Unequal leg lengths
A. Symmetric paralysis of muscles (polio, CP, MD)
What are the sxs of scoliosis?
1. +/- Back Pain
2. Asymmetry in shoulder and iliac crest height
3. Asymmetric scapula prominence
4. Gait normal
5. Neuro exam normal
What dx studies are used in scoliosis?
Standing AP Thoracolumbar X-rays
Curves >15deg significant
What is a Cobb Angle?
1. Measurement perpendicular to end plate of the most tilted end vertebrae
A. Formed between a line drawn parallel to the superior endplate of one vertebrae and a line drawn parallel to the inferior endplate of most tilted vertebrae.
B. Most accurate measurement of degree of spinal curvature
What is the treatment for scoliosis when curves are less than 10 deg?
Follow up q 6-12 months
What is the treatment for scoliosis when curves are less than 20 deg?
1. Managed conservatively
A. Exercise to strengthen muscles & prevent curve progression
Need serial AP X-rays q 3-4 months
What is the treatment for scoliosis when curves are greater than or equal to 20 deg?
Refer to ortho
What is the treatment for scoliosis when curves are 20-40 deg?
A. Back brace
B. Spinal exercises
What is the treatment for thoracic curves >40-50 deg?
Thoracic curves >40-45, pts w/ scoliosis & resp. complaints, and pts w/ scoliosis & neurologic sxs:
Curve may impair resp. function
Define Lumbar Spondylolysis (Pars Defect)?
Unilateral or bilateral stress fx of bridge btw upper and lower pars interarticularis
What is the etiology of pars defect?
LBP cause in children/adolescent athletes
Gymnastics, diving, wrestling, dancing , figure skating etc
What are the dx studies for pars defect?
1. Lumbar X-ray
A. AP, lateral
B. Oblique view
-Scotty dog “collar” or a “broken neck” is pathognomonic finding
2. CT scan
A. If x-ray does not show pars defect
What is the management for a pars defect?
1. 2Refer to Ortho Spine
3. Muscle relaxants
4. Activity modification
6. Pt education
7. Maintaining proper flexibility and spinal stabilization via home exercise program (HEP)
Inc convex curvature of thoracic spine
What can kyphosis be asst with?
present in approx. 33% of pts w/ scoliosis
What are the sxs of kyphosis?
Round back appearance
Excessive lumbar lordosis is common
What imaging is used for kyphosis?
Standing lateral films
What is the treatment for kyphosis?
1. Curves 45-60
A. Follow-up q 3-4 months
2. Curves >60
A. Milwaukee brace
3. Persistent pain
A. Milwaukee brace
A. If conservative treatment fails
Nerve compression caused by narrowing of spinal canal
What are the 2 types of spinal stenosis
1. Central stenosis
A. Compression of thecal sac
B. Membrane of dura mater that surrounds spinal cord and cauda equina
C. Can be idiopathic or developmental
2. Lateral stenosis
A. Impingement of nerve root lateral to thecal sac
What is the pathophys of spinal stenosis?
Narrowing is usually caused by bony hypertrophic changes in the facet joints and by thickening of the ligamentum flavum
What can spinal stneosis cause?
What are the sxs of spinal stenosis?
1. Back pain w/ walking is typical
A. Relieved by leaning forward and sitting
B. Lying prone worsens pain
2. Variable back & leg pain
3. Transient tingling in legs
4. Leg fatigue
A. Usually bilateral
What are the PE components and results for spinal stenosis?
1. Complete spine exam
2. Note presence of leg pain, paresthesias or numbness w/ extension of spine
A. Skin for hairy nevi patches, hemangiomas or dimples on lower back midline
B. Signs of spina bifida, rare in adults
3. SLR (negative in spinal stenosis usually, present in HNP) 30-40deg
4. Patrick’s / FABER test (neg. for stenosis, positive if hip joint etiology)
5. Check distal pulses (vascular claudication)
What Dx studies are used for spinal stenosis?
1. Usually clinical diagnosis, order to confirm dx
A. X-rays: +/- STS, Degenerative disc disease (spondylosis)
B. MRI preferred over CT scan to confirm dx
-Spondylolisthesis can cause spinal stenosis as well
What is the tx for spinal stenosis?
1. Rest, isometric abdominal exercises
2. Weight loss
4. Refer to Spine Surgeon if conservative treatment fails
A. Wide decompression of lumbar canal
Define Ankylosing Spondylitis (AS)
1. Inflammation & progressive fusion of vertebrae with unclear etiology, yet there is a genetic association (prob autoimmune)
2. Affects SI joints symmetrically and spine in progressively ascending manner
Who gets AS?
M>F, Peak age 20–30 yo
What are the sxs for AS?
1. Back pain (anywhere)
2. Progressive stiffness of spine
3. Dec motion in shoulders and hips
4. Compression fractures
5. Synovitis of knees
6. Plantar fasciitis / Achilles tendonitis
What are the complications of AS?
1. Fusion of breastbone/ribs
A. Dec lung capacity and function
2. Extra-articular manifestations
A. Uveitis, cardiac abnormalities, interstitial lung disease
What dx studies are used for AS?
1. HLA-B27 (90% test positive)
2. ESR elevation
3. X-ray Spine
A. “Bamboo spine”
B. Radiographic obliteration and marginal syndesmophyte ossification of paraspinal ligaments
C. Generalized osteopenia of spine
D. AS is one of the seronegative spondyloathropathies
What is the treatment for AS?
2. If Refractory to above
A. TNF inhibitors: Adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade)
3. Physical Therapy
A. Preserve posture
B. ROM and stretching exercises
-Underlying and complicated conditions must be treated
Define Cauda equina syndrome
1. Rare syndrome
2. Large midline disc herniation that compresses several nerve roots
3. Usually involves L4 to L5 level
What are the etiologies of Cauda Equina Syndrome?
1. Large HNP
2. Trauma from MVA or Fall from sign. height
A. vertebral frx
B. epidural hematoma from GSW or stabbing
A. epidural abscess
5. Severe spinal stenosis
6. Very small %age of pts post HNP surgery
What are the sxs of Cauda equina syndorme?
1. Saddle anesthesia
2. Impaired bowel function
3. Impaired bladder function (urinary retention, incontinence)
4. Leg pain & paresthesias
5. +/- paralysis
6. Back pain and urinary retention: Think Cauda Equina
How is cauda equina syndrome treated?
1. Surgical Emergency- spinal decompression
2. Untreated or late sx can result in permanent paralysis and incontinence
What will be seen on PE with CES?
1. LMN injury pattern
2. MSK Neuro
A. LE weakness or paralysis
B. cannot assess gait, toe walking or heel walking
C. LE numbness or decreased sensation
D. LE hyporeflexia or Absent DTR’s
E. negative Babinski and negative Clonus
A. decreased rectal tone
B. saddle anesthesia
What is Brown Sequard syndrome?
1. Hemisection of the spinal cord
2. Ipsilateral lossof tactile sensation and proprioception
3. Contralateral loss of pain and temperature sensation