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Medicine II: Orthopedics > Spine > Flashcards

Flashcards in Spine Deck (59)
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1

Identify the anatomic structures of the entire vertebral column. (Concave vs convex; number of vertebrae; label vertebrae in coronal and lateral views)

xx

2

Spondylolithesis

slipping of one vertebra on another

3

Spondylolysis

pars interarticularis defect

4

Spondylosis

degenerative change, osteophytes, disc space changes

5

Identify which carcinomas are known to metastasize to the spine

Multiple myeloma: Lung 31%, Breast 24%, GI 9%, Prostate 8%

6

Cervical strains

aka Whiplash, Result of sudden hyperextension followed by hyperflexion of the neck.

7

Clinical Presentation of Cervical Strains

Most common cause is from rear-end collisions, sports trauma, repetitive C-spine stretching beyond their physiologic capacity, generating inflammation within the local soft tissues.

8

Symptoms and Exam of a patient with a Cervical Strain

Neck pain, trapezial pain, back pain, muscle spasm, heacache, and limited ROM. (*bogginess of post neck musculature, c-tissue edema (not pitting!), and limited ROM secondary to m. spasm). Often begin ACUTELY, hours after the injury (usually the sx occur the next day). Very minimal long-term sequelae.

9

Diagnosis of Cervical Strains

CLINICAL! Based on H and P and simple tests. Use Xray to help exclude more severe injuries.

NLC- Low Risk Criteria and CCR- Canadian C-Spine Rule. Both the CCR and NLC are proven effective with excellent negative predictive values. Helical CT is faster with better sensitivity (but $$). MRI-used for soft tissues, spinal cord, and ligament.

10

Physical Exam of Cervical Strains

PE- ALWAYS assume DANGEROUS underlying patho and consider c-spine strain ONLY as dx of exclusion. Many times, pt will present w/ C-collar.

First- assess pt for: sobriety, cooperatively, and presence or absence of distracting injury. Check neck for skin integrity, edema, eccyhymosis, and asymmetry. Next, perform detailed neuro exam in UE and LE and then test Cervical ROM.

11

Treatment for Cervical Strains

Clinical course is benign. Most pts will be able to return to normal function in 1-2 weeks. Heat and Ice packs are beneficial (altering 2 for 15-20 minutes per session). C-collar and time off from work are not recommended for C-strain. NSAIDS and analgesia (pain control), Encourage normal use as tolerated, PT.

12

When to refer

Persistent pain over several weeks, abnormal neuro exam or abnormal radiologic findings.

13

Cervical Disc Degeneration

Common cause of neck pain in the elderly, showing decreased ROM, and stiffness. It’s MUCH LESS COMMON than a disc degeneration of lumbar spine (because it’s subjected to much less force). It’s caused from Wear and Tear over time!

14

Clinical Presentation of Cervical Disc Degeneration

Low-grade neck pain, stiffness, and instability. Can present with numbness, tingling, weakness in the neck, arm, or shoulders→ from nerves being irritated/pinched.

15

Imaging for Cervical Disc Degeneration

X-ray to help define problem more clearly. They show a decrease in intervetebral disc space, osteophyte formation, and loss of normal cervical lordosis. Get flexion, extension, AP (for tumor, fractures), and lateral view (anterior osteophytes and disc space narrowing). Use MRI for pts with neuro symptoms.

16

Physical Exam of Cervical Disc Degeneration

Ask the pt to perform flexion, extension, and rotational movements (report if pain decreases/increases). Can become so severe that surrounding osteophytes may encroach spinal canal, leading to spinal stenosis, and myelopathy. Symptoms include stumbled gait, difficult w/ fine motor skills in hands/arms, and shock-type feelings down legs to toes→ NEEDS REFERRAL!

17

Treatment of Cervical Disc Degeneration

Nonsurgical: NSAIDS, PT (freestyle swimming w/ snorkeling gear), Epidural steroids (if needed),
Restoring flexibility helps further repetitive microtrauma, Intermittent C-traction.

Surgical: Only when conservative treatment has failed- Surgery= disc removal, placement of intervetebral bone graft, and fusion. Plate fixation is usually for multiple levels of involvement.

18

Cervical Disc Herniation

Very common cause of neck and arm pain in young adults. Usually caused by traumatic events but can also occur spontaneously

19

Clinical Presentation ofCervical Disc Herniation

Frequent headaches, Pain originating around paraspinal muscle that radiates down one extremity. Finger numbness and/or tingling. Can cause spinal cord compression - disc material pushes directly on spinal cord (more serious- with awkward stumbling gait, tingling, and shock-type feelings down the torso or legs).

20

Special Tests for the Diagnosis of Cervical Disc Herniation

Spurling maneuver→ the head is placed into an extended position, and the patient's chin is rotated toward the affected side. A compressive force is then placed onto the patient's head, and symptoms of nerve impingement are reproduced. On the flip side, patients typically get relief of symptoms when asked to place their hands on top of their heads (abduction relief sign)

21

Physical Exam for Cervical Disc Herniation

Perform careful exam of shoulder and wrist to r/o shoulder/wrist pathology. Numbness, tingling, begins in shoulder and extends down into the fingers. ROM is usually limited secondary to pain. Presents with biceps weakness and pain/numbness in index and thumb. Pain can often be reproduced by spurling maneuver.

22

Imaging for Cervical Disc Herniation

Dx studies → X-rays and MRI. MRI is imaging of choice.

23

Treatment of Cervical Disc Herniation

Nonsurgical: NSAIDS, Cervical epidural steroids, Surgical discetomy and fusion.

Surgical: Only when nonsurgical tx has not worked. Removal of disc through and anterior approach or autograft (bone graft taken from the pt’s iliac crest) can be used.

24

Cervical Spinal Stenosis

The NARROWING of spinal cord-may lead to neural compression and radiculopathy or myelopathy. Some of later sx are bowel/bladder incontinence in a rapid progression.

***Note: it’s very important to recognize possible cervical cord compression early to prevent IRREVERSIBLE damage to cord.

25

Etiology of Cervical Spinal Stenosis

Stenosis=narrowing of the spinal canal and may lead to neural compression, subsequent radiculopathy or myelopathy

Radiculopathy- root compression and symptoms follow dermatomal pattern

Myelopathy – cord compression and symptoms are more diffuse

26

Special Tests for Cervical Spinal Stenosis

Positive Lhermitte sign→ Electric Shock like sensation radiates down spine or extremities w/ certain movements of neck esp flexion/extension.

27

Physical Exam for a patient with Cervical Spinal Stenosis

Neck and arm pain, Numbness and tingling, Clumsiness, loss of fine motor skills, and sensory complaints in UEs. Difficulty walking and imbalance in Les Weakness, bowel and bladder incontinence, and proprioceptive dysfunctions=advanced disease.

+ Lhermitte sign, Cord compression-upper motor lesion-hyperreflexia and upper and lower extremities and ankle clonus (Babinski), Hoffman Spurling.

Jaw jerk test-differentiates cervical myelopathy from lesions in the brain

28

Diagnosis of Cervical Spinal Stenosis

MRI-diagnositc TEST OF CHOICE/CT scan with myelocram is next best if MRI not available

29

Treatment for Cervical Spinal Stenosis

NSAIDs and PT, Epidural steroid injection, Surgical evaluation with abnormal neurologic exam

30

Cause of Cervical Spinal Stenosis

Depends on compression of ant or post structures:
Anteriorly herniated disks; ossification of posterior longitudinal ligament (OPLL); and osteophytic spurs from back of vertebral bodies, endplates, or uncovertebral joints are the common culprits of cord and root compression. Osteophytic spurs develop as reactive response to hypermobility of adjacent degenerative disk (extra note: increased stress on articular cartilage and endplates of vertebrae stimulates osteophytic spur formation as body naturally tries to stabilize spine).

Ligamentum flavum is the main culprit causing posterior compression, losing its tension and buckling into the canal as the disc degenerates anteriorly. It may also hypertrophy or ossify to cause more compression to the spinal cord.

Spinal cord may stretch over anterior osteophyte during flexion or be compressed by ligamentum flavum during extension