Pathologies Related to the Low Back #1

Question 1

What is the number one form of spinal malignancy?

Answer 1

Multiple myeloma

Question 2

What is the second most common spinal malignancy?

Answer 2

Spinal metastases

Question 3

Which region is the most common region for spinal malignancy?

Answer 3

• Thoracic is most common by far (70%)
• Then lumbar
• Rarely cervical

Question 4

About what present of spinal malignancies create cord compressions or myelopathies?

Answer 4

20%

Question 5

What is primarily a malignant tumor in bone marrow and typically found in older individuals?

Answer 5

Multiple myeloma

Question 6

What is the most common tumor of the spine and the second most common serious spinal pathology?

Answer 6

Spinal metastases

Question 7

Where are spinal metastases most often found?

Answer 7

Breast, Lung, Prostate, Kidney, GI, Thyroid (in that order)

Question 8

What is the 3rd most common area of metastasis behind the lung and the liver?

Answer 8

Bone

Question 9

Where are spinal metastases most often found in bone?

Answer 9

In the vertebral body (mostly in the anterior portion leading to wedging)… disc is rarely involved

Question 10

What is the most useful indicator of a spinal malignancy?

Answer 10

97% of spinal tumors are the results of metastasis meaning that PMH of cancer is the most useful indicator

Question 11

What is the gold standard for imaging for spinal malignancy?

Answer 11

MRI

Question 12

What is the pathogenesis of spinal malignancy?

Answer 12

Healthy bone replaced by tumor

Question 13

What are PT implications of spinal malignancy?

Answer 13

• Cancer signs and symptoms like spinal pain (most common initial symptom) and unfamiliar/ severe pain that may become progressive and constant
• Possible bony alterations, including fractures and subsequent joint instability: may be able to lie flat due to the pain, and it is likely mechanical pain
• Biomechanical components that stress vertebral body and lumbar joints will possibly be (+)

Question 14

What are signs and symptoms of cancer?

Answer 14

• History of cancer
• Pain in local or referred areas
• Nausea and vomiting
• Loss of appetite
• Unexplained weight loss of greater than or equal to 5-10% over a 3-6 month period
• Fever, chills, sweats (night): even in absence of infection due to increased circulating white blood cells (WBCs) or production of pyrogen agent
• Swollen and non-tender lymph nodes, possibly hard and immobile due to fibrosis
• Unusual malaise and fatigue
• Secondary infections due to lowered immunity

Question 15

What does pain with cancer look like?

Answer 15

• Worsens as the tumor grows and encroaches on other tissue with more inflammation
• Especially at night, due to tumors metabolic activity, and likely at a similar time after falling asleep
• Often invariable with position or movement
• May become constant

Question 16

What signs and symptoms would likely be present due to involvement of the vertebral body in spinal malignancies?

Question 17

What kind of referral is a spinal malignancy?

Answer 17

Urgent referral to an MD unless there are cord signs and symptoms you would want to immobilize for emergency referral

Question 18

What is the pathogenesis of a lumbar myelopathy?

Answer 18

Slow, gradual, and often progressive compression of the cord

Question 19

What level is the end of the spinal cord?

Question 20

What is the second most common area of the spine for compression?

Answer 20

Lumbar spine

Question 21

Are lumbar myelopathies due to trauma?

Answer 21

No

Question 22

Lumbar myelopathies are most commonly due to what?

Answer 22

Degenerative spinal changes such as:
- Lax and buckling ligamentum flavum
- Age-related joint disease with enlarging and encroaching arthritic bone aka stenosis
- Age-related disc disease with herniations
- Vertebral body collapse/ fracture
- Pathological instability (ex: spondylolisthesis)

Question 23

How often are malignancies are a part of lumbar myelopathies?

Answer 23

20% of the time with the only well validated red flag being a history of cancer

Question 24

Can you have central disc herniations with lumbar myelopathies?

Answer 24

Yes, but they are rare

Question 25

What kind of history might you see with lumbar myelopathy?

Answer 25

Slow, gradual, and often progressive onset

Question 26

What might you observe with lumbar myelopathy?

Answer 26

Not acute so not likely to splint

Question 27

What kind of A/PROM might you see with lumbar myelopathy?

Answer 27

Extreme spinal pain with mechanical reproduction with scan and biomechanical exam, possibly for age-related changes, vertebral body, instability

Question 28

Are PAs positive or negative with lumbar myelopathies?

Answer 28

Positive for neuro symptoms

Question 29

What kind of neuro symptoms might you see with lumbar myelopathy?

Answer 29

- Multisegmental numbness and weakness/ paralysis of lower extremities and trunk below level of injury likely leading to impaired balance - Hyperactive DTRs - Spastic or retentive bowel or bladder - Positive UMN tests - Negative dural mobility due to gradual onset - Hypoactive superficial reflexes

Question 30

What kind of referral is lumbar myelopathy?

Answer 30

Immobilize with emergency referral

Question 31

What is cauda equina syndrome?

Answer 31

- Compression on some degree of the 20 spinal nerves that originate from the end of the spinal cord or conus medullaris in the vertebral canal - Acute or chronic - Below the L1 or L2 segment

Question 32

What is the prevalence of cauda equina syndrome?

Answer 32

Rare with 2% of lumbar age-related disc changes

Question 33

What is the etiology of cauda equina?

Answer 33

- Primarily due to mid to lower lumbar age-related disc changes - Secondarily due to other degenerative spinal changes and malignancy

Question 34

What are the risk factors of cauda equina?

Answer 34

- Mid to lower lumbar persistent IDD (central > posterolateral IDD), central stenosis, surgery - Less than 50 years old - Obesity

Question 35

What are the differences between myelopathy and cauda equina syndrome?

Question 36

What kind of history will someone with cauda equina syndrome present with?

Answer 36

- LBP - Bowel and bladder incontinence - Sexual dysfunction - Possible cancer signs and symptoms if malignancy contributing

Question 37

What movements are worse and what movements are better with cauda equina syndrome?

Answer 37

Likely limited and worse with extension and better with flexion activities

Question 38

What kind of neuro signs will you find with cauda equina syndrome?

Answer 38

- Progressive or even alternating LE/patchy findings due to movement of spinal nerve - Paresthesias and decreased sensation in multiple dermatomes: particularly saddle or groin area - Multiple myotomal weaknesses and gait abnormality - Hypo-activity with DTRs - Possible positive dural mobility tests

Question 39

What kind of referral is cauda equina syndrome?

Answer 39

Likely emergency referral due to multiple spinal nerve involvement

Question 40

What imaging is gold standard for cauda equina?

Answer 40

MRI

Question 41

What is a spinal infection?

Answer 41

Infectious disease of spinal structures

Question 42

What is osteomyelitis?

Answer 42

A bone infection

Question 43

What is discitis?

Answer 43

A disc infection

Question 44

What is the incidence level of spinal infections?

Answer 44

- Uncommon in wealthier countries, but resurgence with longevity and IV drug use - Discitis more common in lumbar spine

Question 45

What is the etiology of spinal infections?

Answer 45

- Primarily from air born bacteria - Secondarily, staph bacteria may also be involved

Question 46

What are risk factors (all low evidence) of spinal infection?

Answer 46

- Immunosuppression - Surgery, particularly of the spine and repeated procedures - IV drug use - Social depravation - History of TB or another recent infection

Question 47

What is the pathogenesis of spinal infections?

Answer 47

- May take days, months or years to spread to the spine - Infection spreads to disc more commonly in lumbar spine - Not common but as abscess grows the following may occur... nerve root irritation, vertebral body collapse or fracture, and cord compression may develop

Question 48

What are the PT implications of spinal infection?

Answer 48

- Age related changes with back pain and stiffness is most common presenting symptom (early signs and symptoms) - Constitutional and infection symptoms not common initially

Question 49

What are infection signs and symptoms?

Answer 49

- Malaise (most common early symptom) - Fever, chills, sweats - Nausea and vomiting - Enlarged (lymphadenopathy) and likely tender lymph nodes - Redness (maybe lymphangitis or streaks toward lymph nodes), abscess, heat, and/or swelling - Specific infected system signs and symptoms as well

Question 50

What kind of (low evidence) implications can spinal infections have?

Answer 50

- Localized and progressive spinal pain that limits motion - Likely mechanical pain for disc is greater than vertebral body involvement with scan and biomechanical exam - Infection signs and symptoms like abnormal fatigue and fever since onset of the back pain

Question 51

If spinal infection is untreated what can happen?

Answer 51

- Unexplained weight loss of greater than or equal to 5-10% over a 3-6 month period with loss of appetite - Neurological signs and symptoms influence the lower extremities and coordination as well as bowel and bladder dysfunction - Loss of lumbar lordosis

Question 52

What kind of referral is a spinal infection?

Answer 52

Urgent referral unless cord or cauda equina signs and symptoms then emergency referral to MD

Question 53

X-rays are helpful in spinal infections if you are suspicious of what?

Answer 53

TB

Question 54

What is the image of choice if TB is not in question for a spinal infection?

Answer 54

MRI, can observe infection 3-5 days after onset

Question 55

How are blood tests helpful in spinal infections?

Answer 55

- Not diagnostic - Inflammatory markers (ex: RBC and C-reactive protein are better indicators of infection than WBC) - Presence of normal WBC does not exclude a spinal infection