quiz - spine

Question 1

where is the problem

Answer 1

-Use a pain diagram
-Does it follow a radicular pattern? -> nerve root vs not
-Does it follow a pattern of referred pain?
-Mechanical symptoms?

Question 2

Red flags

Answer 2

-Is the pain primarily in the back of the leg? -> sciatica
-Bowel or bladder incontinence? -> cauda equina
-Sexual dysfunction? -> cauda equina
Non-dermal or non-anatomic patterns? (e.g..M.S., Lyme, Fibromyalgia)
-DM -> peripheral neuropathy

Question 3

muscle strength grading

Answer 3

(didnt go over it)- told us to look on our own

Question 4

grading reflex

Answer 4

-0= absent
-1+ = hyporeflexic
-2+ = normal
-3+ = hyperreflexia
-4+ = clonus

Question 5

C5, C6, C7, C8, KNOW THIS

Answer 5

-5,6,7- MC pathology here
-motor, reflex, sensation
-C5- deltoid raise, bicep curl, bicep tendon reflex, bicep sensation
-C6- bicep curl, wrist extension, brachioradialis reflex, sensation of first and second fingers
-C7- triceps, middle finger sensation
-C8- no reflex, sensation ulnar aspect of hand

Question 6

T1, L4, L5, S1 -> KNOW THIS

Answer 6

• T1: interosseous fingers, no reflex, lower elbow sensation
  -L4- tibialis anterior (supinate foot), patellar reflex, inside of foot sensation
  -L5- lift big toe, no reflex, sensation is the top of the foot
  -S1- Achilles reflex, lateral aspect of the foot sensation

Question 7

spurling test

Answer 7

-Ask the patient to extend the neck while tilting the head to the side
- This narrows the neural foramen and will reproduce radicular arm pain with cervical disk herniations or cervical spondylolysis

Question 8

axial loading

Answer 8

-with pt standing -> push down on their head
-may provoke neck pain in pts with disk pathology

Question 9

hoffman reflex

Answer 9

-pts hand relaxed -> flick the long finger nail and look for index and thumb flexion -> sign of upper motor neuron interruption (e.g. cervical herniated disk or stenotic lesion)

Question 10

superficial abdominal reflex

Answer 10

-pt supine
-Stroke lightly toward the umbilicus.
-Normal = movement of the umbilicus is toward the stimulated side
-Absence of this may suggest spinal cord pathology in the cervical or thoracic region.
-Perform in uppear & lower quadrants on both sides

Question 11

ankle clonus

Answer 11

-with pt seated, dorsiflex the ankle suddenly and observe for rhythmic beating (clonus)
-Sign of long-tract spinal cord involvement (descending/motor)

Question 12

straight leg raising

Answer 12

-Places the L5, S1, & sciatic nerves under tension.
-Patient supine
-Elevate the leg approximately 80 deg
-Positive if pt has pain radiating down leg
-pain PAST THE KNEE

Question 13

cross leg straight leg raise test

Answer 13

-Supine and raise uninvolved leg
-A greater degree of elevation is usually required
-Pain will radiate on leg not being raised

Question 14

reverse straight leg raise

Answer 14

-Places L1-4 nerve roots under tension
-Pt is prone and the hip is lifted into extension while keeping the knee straight
-Increased pain suggests compression of upper lumbar nerve roots

Question 15

common spinal conditions <10yo

Answer 15

-Congenital Kyphosis
Scoliosis
Intervertebral diskitis
Myelomeningocele- backbone and spinal canal do not close before birth -> type of spina bifida
Osteoblastoma- tumor that replaces bones with osteoid -> benign
Leukemia

Question 16

spinal cord

Answer 16

-ascending fibers- deliver deep touch and vibration, proprioception
-lateral spinothalamic tract- pain and temp (ascending)
-lateral corticospinal tract- voluntary muscle contraction (descending)

Question 17

common spinal conditions: 11-19yo

Answer 17

-spondylolisthesis
-kyphosis (scheuermanns disease)

Question 18

common spinal conditions: 20-29yo

Answer 18

-disk injuries (central disk protrusion, disk sprain)
-spondylolisthesis
-spinal fracture

Question 19

common spinal conditions: 30-39yo

Answer 19

-cervical and lumbar disk herniation or degeneration

Question 20

common spinal conditions: 40-49yo

Answer 20

-cervical and lumbar disk herniation or degeneration
-spondylolisthesis with radicular pain

Question 21

common spinal conditions: 50-59 yo

Answer 21

-disk degeneration
-herniated disk
-metastatic tumors- bone pain that keeps the pt up

Question 22

common spinal conditions: >60yo

Answer 22

-Spinal stenosis
-Disk degeneration
-Herniated disk
-Spinal instability
-Metastatic tumors

Question 23

common terms: Radiculopathy, Myelopathy, Mechanical Pain, Neurogenic Claudication

Answer 23

Radiculopathy
-Dysfunction of a nerve root
-Signs & Symptoms: Pain in the distribution of that nerve root
-Dermatomal sensory disturbances.
-Weakness of muscle innervated by that nerve root.

Myelopathy
-Abnormal condition of spinal cord through ds or compression
-Usual consequences are spasticity, impairment of sensation, & impairment of bowel or bladder function

Mechanical Pain
-AKA musculoskeletal back pain
-MC form of back pain
-May result from strain of paraspinal muscles, ligamentous injury, irritation of facet joints (excludes anatomic causes, e.g. herniated disk, tumor)

Neurogenic Claudication
-“Pseudoclaudication”
-Symptom of Lumbar stenosis causing impingement or inflammation on the nerves
-Symptoms proximal to distal (vascular is distal to proximal)
-Walking & standing causes fatigue & weakness is not relieved with sitting (vascular is relieved with sitting)

Question 24

-paravertebral discomfort relieved with rest and aggravated by activity = what?
-young pt with abnormal upper extremity neuro exam = what?
-older pt with limited ROM and pain on extension -> ?
-urinary dysfunction with global sensory changes, weakness, and abnormal gait -> ?
-shoulder pain and positive impingement -> ?
-tinel sign and non-dermatomal distribution of sx -> ?

Answer 24

-paravertebral discomfort relieved with rest and aggravated by activity -> acute neck sprain
-young pt with abnormal upper extremity neuro exam -> cervical radiculopathy due to herniated nucleus pulposus
-older pt with limited ROM and pain on extension -> cervical radiculopathy due to cervical spondylosis
-urinary dysfunction with global sensory changes, weakness, and abnormal gait -> cervical myelopathy secondary to cervical spondylosis or trauma
-shoulder pain and positive impingement -> shoulder pathology
-tinel sign and non-dermatomal distribution of sx -> peripheral nerve entrapment

Question 25

back pain

Answer 25

-90% of people in their life -2nd MC reason people seek doctor -initial assessment is geared at detecting red flags -without red flags -> imaging is low yield in first 4 wks

Question 26

-Paravertebral discomfort relieved with rest and aggravated with activity -> ? -Limited motion or stiffness -> ? -Unrelenting night pain and weight loss -> ? -Fever chills and sweats -> ? -A younger patient with an abnormal lower extremity neurologic examination ->? -An older patient with poor walking tolerance and a stooped gait ->? -Tenderness over the lateral hip and discomfort at night -> ?

Answer 26

-Paravertebral discomfort relieved with rest and aggravated with activity -> acute low back sprain -Limited motion or stiffness -> degenerative disk disease, ankylosing spondylitis -Unrelenting night pain and weight loss -> tumor -Fever chills and sweats -> infection or intervetebral disk infection -A younger patient with an abnormal lower extremity neurologic examination -> lumbar radiculopathy due to herniated nucleus pulposus -An older patient with poor walking tolerance and a stooped gait -> spinal stenosis -Tenderness over the lateral hip and discomfort at night -> trochanteric bursitis

Question 27

back pain red flags

Answer 27

-cancer or infection: ->50 or <20 yo -h/o CA -wt loss, fever, chills, immunosuppression -UTI, IVDA, prolonged steroids -back pain not improved with rest -spinal fracture: -h/o trauma, MVA, fall from ht -osteoporosis ->70yo and minor trauma -cauda equina syndrome or severe neurologic compromise: -acute onset urinary retention or overflow incontinence -fecal incontinence, decrease rectal tone -saddle anesthesia -global progressive weakness in LEs

Question 28

cervical radiculopathy

Answer 28

-Def: Referred neurogenic pain in the distribution or a nerve root, with or without numbness, weakness, or loss of reflexes MOA: - herniated nucleus pulposus in young pt (< 40) -Older pts -> MC foraminal narrowing from degenerative disk & arthritic facet joint -Sx: neck pain, radicular pain, numbness, muscle spasms, decreased grip strength, loss of coordination -P/E: Loss of cervical lordosis, decreased ROM, + SPURLING test. -Look for changes throughout C4-C7 neuro exam (Pain, Sensory change, Motor weakness atrophy, Reflex change) -Dx tests: X-Ray, MRI or CT confirms dx (not necessary routinely), Electromyography (EMG) - reserved for preop planning Tx: - Resolution of sx usually within 6-12 wks -NSAID’s, oral steroids, phys therapy -Referrals/Red Flags: Failure of conservative tx, atrophy, motor weakness, signs of myelopathy, infection, tumor

Question 29

cervical spondylosis

Answer 29

Def: Degenerative disk ds or cervical ARTHRITIS -MOA: Bone spurs, buckling of the ligamentum flavum, herniated disk -> All result in narrowing of neural foramen and possible stenosis of canal Sx: - Stiffness & neck pain worse UPRIGHT - Muscle spasm, pain with ROM P/E: - Lateral tenderness, spinous process tenderness, Decreased ROM, -Look for changes throughout C4-C7 neuro exam (Pain, Sensory change, Motor weakness atrophy, Reflex change) Dx Tests: X-rays (degenerative changes MC @ C5-6 & C6-7) Tx: - NSAID’s, Supportive (cervical pillow, sleep on side) P.T. -Surgical decompression (laminectomy) - indicated with intractable pain, progressive neurologic findings, cervical myelopathy, spinal cord compression -Referrals/Red Flags: Same as reasons for surgery

Question 30

cervical sprain

Answer 30

-Neck Strain -“muscle” injury in the neck -R/o unstable injuries & neuro dysfunction -> then provide symptomatic tx -Whiplash in MVA is very common -Sx: Nonradicular, nonfocal neck pain anywhere from the base of the skull to the cervicothoracic junction. -Pain with motion, spasm, h/a -P/E: Paraspinous tenderness, decreased ROM, normal neuro exam -Dx Tests: X-rays (AP,Lateral & odontoid views if trauma or neurologic deficit -Tx: Reassurance, Soft collar, NSAID’s, muscle relaxers, cervical pillows, physical therapy -Encourage a return to normal activities! -Referral/Red Flags: Pain refractory to tx, nerve root deficit, myelopathy

Question 31

cervical fracture

Answer 31

-result of high energy trauma -Sx: Severe pain, spasm, POINT TENDERNESS -Global sensory or motor deficits suggest spinal cord injury -P/E: Palpate for tenderness and spasm. -Feel for any gaps or step-off -Check sensory of dermatomes and motor function -> Perianal sensation, sphincter tone & bulbocavernosus reflex should be assessed -Bulbocavernosus reflex = stimulate glans penis or clitoris and monitor anal tone -> Often monitored via emg. -Dx Tests: AP, Lateral, Odontoid -Injuries @ upper & lower portions of C-Spine most often missed. - -!! acute situation CT scan is obtained******** -AP- malalignment of spinous processes -Lateral- anterior soft-tissue swelling, vertebral height, alignment of vertebral bodies, facet joints, & spinous processes Odontoid- subtle fracture, C1 lateral mass widening, occipital condyle position -Swimmers View - visualizes cervicothoracic junction -Carefully evaluate radiographs -Signs of instability (dont memorize #s) ->3.5 mm translation of a vertebral body ->11 degrees of angulation of adjacent vertebral bodies -Tx: Immobilization and/or surgical management if indicated -high suspicion for injury in pts intoxicated, uncooperative, or unconscious

Question 32

fracture of thoracic and lumbar spine types and PE, sx

Answer 32

-high-energy trauma -Can occur with minimal trauma in those with osteoporosis, tumors, infection, chronic steroid use -Sx: Moderate to severe back pain. Worse with motion. -P/E: Step-off or gap between spinous processes with swelling & hematoma are classic in an unstable flexion-distraction or burst fracture -Neuro exam, Perianal sensation, sphincter tone & bulbocavernosus reflex should be assessed Types: -Simple Compression Fracture - involve only the anterior half of the vertebral body are stable -Burst Fracture - compression fracture that extends to the posterior third of vertebral body -Flexion-distraction - disrupts anterior & posterior bone & ligamentous structures. Highly Unstable!

Question 33

fracture of thoracic and lumbar spine dx and tx

Answer 33

-Dx. Tests: AP & Lateral X-rays -!!In acute situation CT scan is obtained**** -AP: Look for transverse fractures or widening of the interpedicular distance (unstable burst) -Lateral: Loss of height of the anterior wall and resultant kyphotic deformity. Widening of the space between adjacent spinous processes Tx: Goals -1) Prevent neurologic damage -2) Restore stability -3) Restore Normal function -Hyperextension bracing, Pain management, phys. Therapy, encouragement, -Surgical intervention

Question 34

kyphoplasty/vertebroplasty

Answer 34

Kyphoplasty = cement is injected into a balloon Vertebroplasty = cement injected into vertebra

Question 35

low back sprain

Answer 35

-Muscular low back pain / Lumbar pain -< 45 y.o. = MCC of loss of work & disability -4% of pts have sx that last >6 months & generate 85-90% of costs to society for treating LBP -RF: repeated lifting/twisting, vibrating equipment, poor fitness, poor work satisfaction, smoking, illness anxiety disorder (hypochondriasis) -Sx: radiates into buttocks and posterior thighs, Pain with lifting and rotation. -P/E: Diffuse paraspinal tenderness, Decrease ROM, Motor, Sensory and reflexes are normal -Dx. Tests: X-rays show degenerative signs and are often not useful -> BUT are necessary to r/o other causes. -Tx: - Bed rest? (1-2 days only) -> avoid it -> keep moving! -NSAID’s, muscle relaxers, APAP, Physical therapy -Referral/Red Flags: Neurologic abnormalities, unresponsive pain

Question 36

degenerative disk ds

Answer 36

-Degeneration of intervertebral disk - physiologic event of aging -Sx: - Usually between 3rd & 6th decade -Recurrent & episodic -LBP that radiates to buttocks -“Mechanical” pain -Relieved with lying down -Depression complicates chronic LBP -P/E: - Lumbar & Sacroiliac tenderness. -Muscle spasm -Motor, Sensory, Reflexes are normal Dx. - X-Rays: AP & Lateral: osteophytes, reduced height of intervertebral disks tx:- chronic pain management problem -NSAID’s, APAP, Lifestyle changes (wt loss, smoking cessation, increased physical activity) -Physical therapy -Referral/Red Flags: Fever, chills, unexplained wt loss, Ca, significant night pain, pathologic fracture, loss of bowel or bladder function, abdominal pain, saddle anesthesia

Question 37

lumbar herniated disk

Answer 37

-Sciatica / Lumbar radiculopathy -Pain from direct compression of the nerve root & in part from chemical irritation of the nerve root by substances in the nucleus pulposus -Affects 2% of the population -10- 20% of those pts have sx lasting longer than 6 wks -Sx: Unilateral radicular leg pain with LBP -Pain worse with sitting -Lying relieves pain -P/E: Inspect for list to one side + SLR test or contralateral SLR test -Dx. Tests: -X-rays: show degenerative changes -MRI for dx or pre-op planning Tx: -1-2 days bed rest for acute episode -NSAID’s, APAP, Muscle relaxers, Oral steroids, epidural injections, Phys. therapy -Referral/Red flags: Cauda equina syndrome, urinary retention, perianal numbness, motor loss, severe single nerve root paralysis, progressive neurologic deficit, radicular symptoms >6wks

Question 38

lumbar herniated disk classic findings: - L3-4 - l4-5 - l5-s1

Answer 38

-L3-4 disk (5%): Ant tib weakness, numbness in shin, asymmetric knee reflex -L4-5 disk (67%): EHL weakness, numbness top of foot & 1st webspace -L5-S1 disk (28%): Weakness with plantar flexion (gastrocsoleus, numbness lateral foot, asymmetric ankle reflex

Question 39

lumbar spinal stenosis

Answer 39

-Neurogenic claudication -Narrowing of the lumbar spinal canal & subsequent compression of the nerve roots -30% of the population >60 y.o. -L4-5, L3-4, L1-2 MC -must have Severe stenosis before symptoms occur -Sx: Neurogenic claudication with radicular complaints -Proximal → Distal -Pain with walking that does not subside when walking stops -Pain with extension (narrows the canal) -P/E: - Muscle weakness in legs -Can have sensory changes -Can have diminished reflexes -Dx. Tests: X-rays: AP & Lateral -May show intervertebral disk narrowing, spondylolisthesis, osteopenia -MRI to confirm -Tx: - * Prevent progression* -Physical therapy, Abdominal muscle strength, weight loss, lumbar flexion exercises, NSAID’s -50% relief with injections

Question 40

spondylolisthesis: degenerative

Answer 40

-Forward slippage of a lumbar vertebral body -Caused by degeneration & alterations in facet joints along with degeneration of intervertebral disk -The lamina and pars interarticularis are intact -M.C. 4th & 5th vertebral bodies -Woman >40 y.o. -Sx: Back pain aggravated with activities -P/E: -Note gaps or step-off -Evaluate motor, sensory function & reflexes (diminished knee & ankle reflexes) -Dx. Tests: X-rays: AP & Lateral -Lateral shows slippage of one vertebra onto another -Degenerative changes and vertebral space narrowing Tx: - Flexion exercises, stretching, corset, NSAID’s. -Lifestyle changes -MRI & consideration of surgical stabilization

Question 41

spondylolisthesis: isthmic

Answer 41

-Forward slippage of a lumbar vertebral body -In children between L5 & S1 -!Defect! at junction of lamina with the pedicle (pars interarticularis), leaving the posterior element without a bony connection -“Fatigue Fracture” -Defect only = Spondyloysis -Gymnasts/Football players -Sx: - Asymptomatic/minimal sx/back pain with posterior radiation -Hamstring spasms & limited hamstring flexibility -P/E: - Palpate for step-off -Diminished lordosis -Neurologic deficits are rare -Dx.Tests: - X-Rays- AP/lateral/oblique. Absent neck in the “Scotty Dog”(pars interarticularis defect) -Differential: Intervertebral disk injury -Tx: Strengthening with P.T. -Periodic (6mo) radiographs until growth is complete -Modification of activities -Thoracolumbosacral orthosis for pain relief -Surgical fusion for progressive slippage -referral/red flags -> progressive slippage and significant pain

Question 42

cauda equina syndrome: causes, sx, classic patterns

Answer 42

-conus medullaris (distal spinal cord) terminates at L1-2. -Spinal canal is filled with L2-S4 nerve roots= Cauda Equina -sudden reduction in the volume of the lumbar spinal canal causes compression and paralysis of roots distal to the conus -Prevalence is low: 1-2% of patients who undergo surgery for HD. .0004 in all patients with LBP -Causes: -HD -Epidural abscess -Epidural hematoma -Fracture -Sx: - Radicular pain and numbness in legs -Pain decreases as paralysis progresses -Difficulty voiding or loss of urinary and anal sphincter control -Urinary retention is most consistent feature (90% sensitive) -Saddle anesthesia -3 Classic Patterns -Group 1: Sudden onset with no previous symptoms -Group 2: Previous low back pain and/or unilateral radicular symptoms that results in cauda equina syndrome -Group 3: Low back pain and bilateral radicular symptoms that evolve into cauda equina syndrome

Question 43

cauda equina syndrome dx and tx

Answer 43

-P/E: -Observe: Inability to rise from seated position or walk on heels and toes (multiple nerve root dysfunction) -Evaluate motor and sensory function -Anal sphincter tone and perianal numbness -Dx Tests: -X-Rays: evaluate for fracture , spondylolisthesis -CBC & ESR to r/o infection -Differential: Guillain-Barre Synd., HD, Mets, MS, Spinal cord tumor -Tx: Surgical Emergency - Requires immediate decompression

Question 44

spinal orthotics: soft cervical collar (dont need to know orthotics)

Answer 44

-Short-term use in cervical sprains or intermittent use with cervical spondylolysis -Position the neck in approx. 10 degrees of flexion -Maintain isometric exercises with its use

Question 45

spinal orthotics: philadelphia collar

Answer 45

-Provides better control of rotation -Used for acute sprains or suspected fractures

Question 46

spinal orthotics: rigid cervical orthotic

Answer 46

-Miami J orthosis -Hard cervical collar that limits flexion & extension -Has a rigid plastic component that extends to chest

Question 47

spinal orthotics: halo brace

Answer 47

-Provides superior immobilization to the C-spine -Virtually no cervical spinal motion occurs

Question 48

spinal orthotics: thoracolumbosacral corset

Answer 48

Provides support for patients with osteoporosis or acute thoracic sprains

Question 49

spinal orthotics: jewett three point orthosis

Answer 49

-Three-point fixation over sternum and pubis anteriorly and mid-spine posteriorly -Limit flexion/extension. Allows limited rotation -Used for thoracic sprains and simple compression fractures

Question 50

spinal orthotics: total contact thoracolumbar orthosis

Answer 50

-Prefabricated modules or made from a plastic mold based on patient’s measurements -Used as definitive treatment in patients with stable burst fractures of the thoracolumbar spine or as post-op aid after spinal fusion

Question 51

spinal orthotics: elastic belts

Answer 51

May provide some lumbar and abdominal support with mild strains

Question 52

spinal orthotics: lumbosacral corset

Answer 52

-Limit motion and are useful for a lumbar strain or acute HD -Limit its use and provide back strengthening once its use is completed

Question 53

cervical facet injection

Answer 53

-Can be used to dx or treat -Local anesthetic & corticosteroid -Done under fluoroscopy

Question 54

interlaminar epidural injection

Answer 54

-Into the epidural space (surrounding the dura) -Herniated Disk / Degenerative changes -Local anesthetic & corticosteroid -Done under fluoroscopy

Question 55

lumbar caudal epidural injection

Answer 55

-Into the epidural space (surrounding the dura) -Herniated Disk / Degenerative changes -Often used when patient has hardware in place -Local anesthetic & corticosteroid -Done under fluoroscopy

Question 56

surgical tx for back pain: when is it indicated

Answer 56

-In general surgical intervention is not recommended for primary back pain -There is not positive outcomes in terms of pain relief, return to work or improved functional ability -Surgical indications include pain not responsive to conservative care -Urgent Surgery; -Cauda equina syndrome -Progressive motor deficit (e.g. foot drop) -Pain (relative indication)

Question 57

surgical tx: cervical herniated disk

Answer 57

- anterior cervical disketomy and fusion (ACDF) - needs 1-2 days in hospital

Question 58

surgical tx: lumbar herniated disk

Answer 58

-Usually Microdiscectomy - Can be outpatient -Chances of recurrent HD are 4-10% and greatest in the first year

Question 59

surgical tx: spinal stenosis

Answer 59

Lamincectomy - Removes the lamina to relieve pressure on the nerve roots. Also allows access to the disk

Question 60

surgical tx: disk replacement

Answer 60

-Preserve motion thus preventing adjacent level breakdown and allowing for more normal biomechanics -Long-term data not available -Technically difficult operation

Question 61

A 48 y.o. Female presents to the urgent care clinic complaining of severe low back pain for the past 3 days. It first began while she was stretching her back before exercising. The pain is constant, 8 out of 10 in severity, and shoots down her right leg from her buttocks to her feet like a “lightening bolt”. She denies fevers, chills, nausea, vomiting, weight loss, or recent trauma. On exam she has a positive straight leg raise and crossed straight leg left test, and her patella reflexes are 2+ on the left and 0 on the right. The achilles reflexes are 2+ bilaterally. Her right quadriceps is weaker than her left, and she is unable to dorsiflex her right foot with any power. Plantar-flexion seems to be spared. The diagnosis and treatment for this patient are: Cauda equina syndrome, immediate surgical consult Spinal stenosis, corticosteroids Musculoskeletal strain, acetaminophen and restricted activity Spinal cord tumor, immediate local irradiation Radiculopathy, anti-inflammatories

Answer 61

The diagnosis and treatment for this patient are: Cauda equina syndrome, immediate surgical consult Spinal stenosis, corticosteroids Musculoskeletal strain, acetaminophen and restricted activity Spinal cord tumor, immediate local irradiation Radiculopathy, anti-inflammatories e) e) Radiculopathy, anti-inflammatories “Classic”- pain shooting from back down leg = radiculopathy Loss of patella reflex and normal achilles= radiculopathy to L4 Weakness of dorsiflexion= L5 is involved Normal achilles reflex & normal plantar flexion = S1 is spared