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Clin Med- P > ortho- spine > Flashcards

ortho- spine Flashcards

1
Q

what does IPROMST stand for?

A

inspection, palpation, ROM, special tests

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2
Q

___% of US adult pop is disabled due to LBP (low back pain)

A

1-2%

*and makes up 1/3 of all disability costs

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3
Q

neck/arm pain- degenerative process begins in what decade? what about symptoms?

A

degenerative process begins in 3rd (30s) decade. Symptoms common in aged 40-60

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4
Q

initial Dx of neck + arm pain: imaging

A

Xray

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5
Q

initial Dx of neck + arm pain: activity or rest?

A

Activity modification, not bed rest!! - bed rest is about the WORST thing you can do

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6
Q

what % of neck/arm pain get better with conservative measures? what are these?

A

75%
analgesiscs, NSAIDs, muscle relaxants (sedating)
steroids- epidural or oral
PT, heat + ice, massage

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7
Q

4 signs further eval needed with neck/arm pain

A
  1. Continued severe arm pain for 10+ days without benefit from conservative txt
  2. Chronic relapsing arm pain
  3. Significant weakness that does not resolve with therapy
  4. Signs of cord compression - Myelopathy
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8
Q

how can cervical spine give a similar presentation to rotator cuff injury?

A

Cervical nerve roots C4-6 innervate the rotator cuff muscles
Sensory distribution runs from base of neck to outer edge of shoulder. Any of these nerves can produce pain in the scapula, shoulder, upper / lower arm, hand
***NEED meticulous PE to determine which is which

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9
Q

most common location of radiculopathy, cause?

A

Most common location C5, C6, C7: Due to increased motion

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10
Q

what is radiculopathy?

A

radiculopathy- means youre pushing on the nerve roots
weakness WITH pain
weakness without pain is likely NOT radiculopathy

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11
Q

painless weakness is common or rare?

A

rare

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12
Q

acute cervical disc protrusions: two types

A

lateral and central herniations

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13
Q

lateral disc herniation can cause what?

A

motor, sensory, or reflex changes in a radicular (usually C6 or C7) distribution on affected side
Leads to pain in the neck and radicular pain in the arm, exacerbated by head movement

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14
Q

central disc herniations can cause what?

A

spinal cord may be involved

significant CNS dysfunction-Spastic paresis, sensory disturbances, impaired sphincter function

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15
Q

Dx of an acute cervical disc protrusion is confirmed what two possible ways?

A

confirmed by MRI or CT myelogram

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16
Q

what is spurling’s test?

A

Foraminal compression - test cervical nerve root irritability -Standing behind the patient, head is bent backwards and flexed laterally to the symptomatic side.
This posture may elicit pain or paresthesia in the involved root.
- positive: pain recreated
= Dx cervical radiculopathy (herniated disc)

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17
Q

4 tests for rotator cuff /impingement (provocative tests)

A

Neer’s
Hawkins’
Jobe’s (empty can)
Drop arm

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18
Q

clinical symptoms of rotator cuff injury (4)

A

Pain with Abduction
Pain with lowering a fully raised arm
Atrophy of shoulder muscles
Weakness with arm rotation

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19
Q

clinical symptoms of cervical radiculopathy (3)

A

Reduction in pain with arm Abduction (decreases nerve root tension)
Sensory changes along dermatome
Small percentage will have painless weakness

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20
Q

what imaging would you do for rotator cuff tear vs cervical radiculopathy? (5) which is the best?

A 
Xray (AP + lateral) 
MRI (BEST)
Myelogram (2nd best) 
CT (last choice) 
Bone scan: malignancy/infection
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21
Q

most common initial symptoms of spinal cord compression (3)

A

Usually lower limbs – dragging or shuffling
Clumsiness of hands and fingers
Difficulty intitiating micturition (urinating)

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22
Q

what is the pain and neurodeficit like with spinal cord compression? (kinds weeds)

A

Central pain - Diffuse, dull, aching, burning
Involving limbs or side of trunk
Flex/Ext cause electric shock pain or tingling

Neurologic deficit
Progressive weakness
Sensory disturbance
Sphincter disturbance

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23
Q

is spinal cord compression dangerous?

A

a neuro emergency!!!

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24
Q

Dx imaging for spinal cord compression

A

MRI

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25
Q

while MRI is great at imaging soft tissue structures, eval of shoulder girdle, disc herniation, metastasis, tumor infections… what is it NOT good at imaging

A

Limited in the evaluation of fusion and hardware placement

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26
Q

what is CT imaging good for? (3) what is it the best tool for?

A
  1. evaluating the osseous anatomy in multiple planes
  2. presence of osseous fusion in post surgical patients
  3. Evaluation of hardware
    * **Best tool for evaluating the osseous anatomy in multiple planes
    * fast and available
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27
Q

downfall of CT

A

ionization radiation exposure

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28
Q

what is myelography ?

A

Radiologist injects iodinated contrast material into thecal sac
Multiple X-rays taken often with patient standing and in extension and flexion
*CT scan performed after injection

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29
Q

when is myelography used?

A

when pt can’t have MRI

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30
Q

cervical spondylosis: what is it? (4 parts)

A

Chronic disk degeneration–> Herniation–> Secondary calcification
1+ nerve roots impinged from herniations or osteophytic outgrowths
*myelopathy may develop

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31
Q

symptoms of cervical spondylosis

A

Neck pain, decreased ROM
Occipital HA
Radicular pain
Sensory or motor deficits

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32
Q

Most common type of spinal cord dysfunction in patients > 55 years

A

spondylosis w/ myelopathy

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33
Q

signs of sondylosis w/ myelopathy - in order of when they show up (3)

A
  1. gait spasticity
  2. upper-extremity numbness and loss of fine motor control in the hands
  3. late sign bladder dysfunction
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34
Q

recommended txt for spondylosis w/ myelopathy

A

conservative treatment is NOT indicated (unlike most degenerative conditions of the back)
- recommended: surgery relatively early (within 1 year of symptom onset)

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35
Q

symptoms of spondylosis w/ myelopathy

A
  1. Pain in the neck, subscapular area, or shoulder
  2. Anesthesias or paresthesias in the upper extremities
  3. Sensory changes in the lower extremities
  4. Motor weakness in the upper or lower extremities
  5. Gait difficulties
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36
Q

what is needle EMG (electromyelography) useful for? (neck pain) (weeds)

A

Needle EMG can detect acute, subacute, and chronic radicular features if motor nerve fiber pathology exists.

NCS(nerve conduction study) /EMG : differentiating cervical radiculopathy from confounding neuropathic conditions (eg, ulnar nerve entrapment, carpal tunnel syndrome, peripheral neuropathy, plexopathy).

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37
Q

when are diagnostic injections useful? (neck pain)

A

If pathology appears to be coming from shoulder, subacromial injections may be helpful

If appears to be coming from cervical spine, selective nerve root injection

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38
Q

who needs surgery with neck pain? (2 groups)

A
  1. Neurologic Compromise: Symptomatic nerve root compression refractory to medical management
    (Cord compression with myelopathy)
  2. Mechanical Instability
39
Q

3 mechanical lumbar syndromes (with examples)

A
  1. aggravated by static loading of the spine: ie, prolonged sitting or standing
  2. long lever activities: ie, vacuuming or working with the arms elevated and away from the body
  3. levered postures: ie, bending forward
40
Q

mechanical make up about how much of LBP cases?

A

98%

Others due to systemic, visceral, or inflammatory disorders

41
Q

nonmechanical back pain types

A

neurological syndromes, systemic disorders, referred pain

42
Q

**>50 yo with spine pain, what three things must be in your differential

A

AAA
Fx (fracture)
malignancy

43
Q

**<18yo with spine pain, what must be in your differential (5)

A 
Spondylolysis
Spondylolisthesis
Infection
Tumor
Developmental disorders
44
Q

what is most telling for ROM with spine pain ?

A

forward flexion

45
Q

muscle testing 0-5: what are 3 important things to watch for?

A
  1. Weakness vs. give-way weakness (i.e. drop arm)
  2. Ratchety weakness (i.e. parkinson)
  3. SLR: straight leg raise
    Dissociation between SLR sitting or lying
    ipsilateral leg pain when supine = +
46
Q

7 Red Flags in spinal exam

A 
B/B incontinence or retention
Saddle anesthesia
History of trauma
Bilateral neurologic deficits
Progressive neurologic impairment
fever 
night pains
47
Q

Dx of spine pain: when are xrays useful

A

not routine, only if malignancy, infection, fx, spondylosis or listhesis

48
Q

Dx of spine pain: when is CT useful?

A

when bony pathology suspected (fx, spondylosis)

49
Q

Dx of spine pain: when is MRI useful?

A

for: soft tissue, nerve, routes, couda equina!!!**

HNP and stenosis

50
Q

urgent studies when red flags present: Xray (4)

A

Trauma
Children
Infection
Malignancy

51
Q

urgent studies when red flags present: MRI

A

Cauda Equina
Epidural hematoma
+ get pre-op labs if you think theyll need surgery

52
Q

Cauda Equina Syndrome (CES)

A

Cauda Equina: L2-S4 nerve root (below conus medullaris)

Compression of the roots distal to conus causes paralysis w/o spasticity

53
Q

what does CES result from? (pathophysc)

A

relatively sudden reduction in the volume of the lumbar spinal canal that causes compression of multiple nerve roots

54
Q

what nerve roots are especially vulnerable in CES?

A

S2-S4 roots that control bladder and anal function are particularly vulnerable

55
Q

4 general causes of CES

A

Central disk herniation
Epidural abscess
Spinal trauma: Burst fx with retropulsion or Epidural hematoma
Tumor

56
Q

symptoms of cauda equina syndrome

A

Perineal numbness (saddle) ~75%
Urinary overflow incontinence or retention ~90%
Leg weakness (often presents as stumbling gait) / bilateral numbness in legs
Can be immediate or over a few hours or a few days

57
Q

CES exam shows what two things

A

Inability to rise from chair without use of armrests: Quad and/or hip extensor weakness
Inability to walk on heels or toes: DF and PF weakness

58
Q

Dx of CES

A

MRI (+maybe AP xray for structural problems)
blood labs for suspected infection ( CBC, Creative protein, ESR)
preop labs

59
Q

Txt + prognosis of CES

A

txt: Usually requires emergent decompressive surgery
Stop progression of deficits
prognosis Recovery often incomplete
Bowel and Bladder function remain impaired

60
Q

4 stages of disc herniation

A

degeneration, prolapse (bulge) , extrusion (leak out) , sequestration (effect to lower spinal levels)

61
Q

sciatica: technical and real world definition. what would be a better term?

A

leg pain: 1+ lumbosacral nerve roots, typically L4-S2, with or without neurological deficit.
common definition: leg pain from any lumbosacral segment as sciatica.
Better term: nonspecific radicular pattern

62
Q

what causes herniated nucleus pulposus (HNP), degenerative disc disease (DDD)? (pathophys)

A

Discs lose hydration and elasticity with age
Leads to… fissures, loose ligaments, Traction spurs
+ Disk collapse

63
Q

DDD/HNP –> spondylosis

A

Canal and foramen narrows
Facet hypertrophy narrows foramen
Osteophytes develop

64
Q

radicular pain: are both legs hurting the same or one more than the other?

A

one more than the other

65
Q

oral pharm options for spine pain

A

NSAIDS, muscle spasmolytics, neuro pain analgesics (gabapentin), antidepressants (TCAS, SSRIs)
*opiods-last resort or SEVERE ACUTE

66
Q

4 types of topical therapy for back pain

A

NSAIDs
Local anesthetics
TCAs
Compounding (combo of drugs)

67
Q

spinal interventional procedures (7)

A

Intra-articular facet blocks
Sacroiliac joint injections
Epidural injections
Intradiskaltherapies
Spinal cord stimulation
Implantable intrathecal drug administration systems
surgery( Diskectomy, foraminotomy, medial facetectomy, and/or hemilaminectomy)

68
Q

is there a relationship between the extent of disk protrusion and the degree of clinical symptoms?

A

NO!

69
Q

Sciatica due to lumbar intervertebral disk herniations usually resolves with _______ treatment!

A

conservative

70
Q

Txt for acute compression fracture of the spine (6 steps)

A 
Supine: pt remain on their back 
Logroll: only way they can be moved 
Examine for other injuries
Completion films: x rays 
Analgesics
Brace vs. surgery
71
Q

what is kyphoplasty?

A

filling a vertebral body broken from compression fracture w/ cement

72
Q

spondylolysis vs spondylolithiesis

A

bone deficit in pars intra-articularis (between superior + inferior articular facet) with…
no slip = spondylolysis
forward slip of one vertebrae = spondylolithiesis

73
Q

the slip of the vertebrae in spondylolitheisis can compromise what?

A

either the central canal space and/or the foramina.

74
Q

what people get spondylolitheisis

A

More prominent in groups of people who place a lot of stress on their backs (ie. manual laborers, heavy machine operators, and professional athletes)

75
Q

what is lumbar spine stenosis?

A

Usually result of aging and everyday wear and tear on the spine
Narrowing of one or more levels of lumbar spinal canal
Compression of nerve roots or conus

76
Q

cause of lumbar spine stenosis in elderly vs young

A

In elderly, typically degenerative in origin

In young, d/o that cause small canal

77
Q

lumbar stenosis symptoms

A 
Insidious or sudden onset without injury
Neurogenic claudication
Radicular symptoms w or w/o back pain
One or both legs
Differs from vascular claudication, but can co-exist
78
Q

what may cause lumbar stenosis patients some relief? why?

A

Extension of spine narrows the canal and flexion opens the canal
So pts get brief relief by leaning forward, stooping
Ie. Lean over grocery cart

79
Q

neurogenic vs vascular claudication: back pain (which is common?)

A

neurogenic: common
vascular: uncommon

80
Q

neurogenic vs vascular claudication: pain relief

A

neurogenic: sitting or flexed posture
standing + resting usually not helpful (often slow > 5 min)
vascular: NOT positional
pain relief while standing, ( immediate)

81
Q

neurogenic vs vascular claudication: ambulatory tolerance

A

neurogenic: tolerable
vascular: fixed

82
Q

neurogenic vs vascular claudication: uphill vs downhill

A

neurogenic: downhill more painful (extended posture)
vascular: uphill more painful

83
Q

neurogenic vs vascular claudication: bicycle ride

A

neurogenic: no pain
vascular: pain

84
Q

spinal stenosis exam findings (5)

A 
True weakness uncommon or late finding
Sensory changes segmental if at all
Diminished reflexes
Normal pulses
Normal sphincter tone, though B/B Sx may be present
85
Q

Dx of spinal stenosis

A

CT

MRI more precise- just takes longer + more expensive so not as widely used

86
Q

leg pain predominates and imaging ambiguous, what three tests should you do for Dx?

A

EMG (electromyography)
SSEP (somaotsensory evoked potential testing)
SNRB (selective nerve root block)

87
Q

lumbar spinal stenosis txt (4)

A

NSAIDs (monitor renal function)
Physical Therapy - Aquatics
Epidural Steroid Injections (ESI)
Surgery for those who are becoming non-ambulatory or decreased quality of life

88
Q

what txt has great outcomes with lumbar spinal stenosis

A

Surgical decompression

89
Q

when is low back pain defined as “chronic”?

A

after 3 months because most normal connective tissues heal within 6-12 weeks, unless anatomic instability persists

90
Q

Primary cause of absenteeism from work

AND Most common cause of disability in American males < 45

A

chronic low back pain

91
Q

chronic low back pain: Of those individuals who remain disabled for more than ___ months, fewer than _____ return to work.

A

6 months, fewer than 1/2 return to work.

92
Q

4 barriers to recovery of chronic low back pain (kinda weeds)

A 
medical/surgical (physical) 
pyschological (i.e. dementia) 
nonpyschological (i.e. brain damage) 
social (i.e. compensated unemployment) 
traumatic factors (i.e. fear) 
post-traumatic factors (i.e. anxiety/depression)
93
Q

prognostic red flags for chronic low back pain

A
  1. Nonorganic signs and symptoms
  2. Dissociation between verbal and nonverbal pain behaviors
  3. Compensable cause of injury (worker’s comp)
  4. Out of work, disabled, or seeking disability
  5. Psychological features, including depression and anxiety
  6. Narcotic or psychoactive drug requests
  7. Repeated failed surgical or medical treatment for LBP or other chronic illnesses

Clin Med- P (124 decks)

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