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Spine Flashcards

1
Q

Cervical nerve root relationt o vertebrae

A

• 7 cervical vertebrae; 8 cervical nerve roots

nerve root exits above vertebra (i.e. C4 nerve root exits above C4 vertebra), C8 nerve root exits below C7 vertebra

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2
Q

Radiculopathy definition

A

impinegement of nerve root

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3
Q

Myelopathy deifnition

A

impingement of spinal cord

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4
Q

Cervical spine special testing

A
  • compression test: pressure on head worsens radicular pain
  • distraction test: traction on head relieves radicular symptoms
  • Valsalva test: Valsalva maneuver increases intrathecal pressure and causes radicular pain
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5
Q

C5 motor, sensory and reflex

A

Motor - Deltoid
Biceps
Wrist extension

Sensory -
Axillary nerve

Reflex - biceps

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6
Q

C6 motor, sensory and reflex

A

Motor -
biceps
brachioradialis

Sensory -
thumb

Reflex -
biceps
brachioradialis

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7
Q

C7 motor, sensory and reflex

A

Motor -
triceps
wrist flexion
finger extension

sensory -
index and middle finger

reflex -
triceps

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8
Q

C8 motor, sensory and reflex

A

motor -
interossei
digital flexors

sensory -
ring and little finger

reflex -
finger jerk

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9
Q

Appropriate cervical neck anterior soft tissue space

A

C3 0-3 mm

C4 0-10 mm

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10
Q

DDx of C-spine pain

A

neck muscle strain, cervical spondylosis, cervical stenosis, RA (spondylitis), traumatic injury, whiplash, myofascial pain syndrome

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11
Q

Where does the spinal cord terminate

A

Conus medullaris (L1/2)

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12
Q

Relation of nerve roots to vertebra in the thoracolumbar spine

A

individual nerve roots exit below pedicle of vertebra (i.e. L4 nerve root exits below L4 pedicle)

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13
Q

Thoracolumbar spine special tests

A

• straight leg raise: passive lifting of leg (30-70°) reproduces radicular symptoms of pain radiating down posterior/lateral leg to knee ± into foot

Lasegue maneuver: dorsiflexion of foot during straight leg raise makes symptoms worse or if leg is less elevated, dorsiflexion will bring on symptoms

• femoral stretch test: with patient prone, flexing the knee of the affected side and passively extending the hip results in radicular symptoms of unilateral pain in anterior thigh

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14
Q

Lumbar radiculopathy/neuropathy motor/sensory, screening test, reflex, test for L4

A

Motor -
Quadriceps (knee extension + hip adduction)
Tibialis anterior (ankle inversion dorsiflexion)

Sensory - medial malleolus

Screening test - squat and ris

Reflex - patellar

Test - femoral stretch

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15
Q

Lumbar radiculopathy/neuropathy motor/sensory, screening test, reflex, test for L5

A 
Motor - 
Extensor hallucis longus 
Gluteus medius (hip abduction)

Sensory -
1st dorsal webspace and lateral leg

Screening test -
heel walking

Reflex - 
medial hamstring (unreliable)

Test -
straight leg raise

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16
Q

Lumbar radiculopathy/neuropathy motor/sensory, screening test, reflex, test for S1

A

Motor -
Peroneus longus + brevis (ankle eversion)
Gastroc + soleus (plantar flexion)

Sensory - lateral foot

Screening tst - walking on toes

Reflex - Achilles

Test - straight leg raise

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17
Q

Ddx of back pain

A
  1. . mechanical or nerve compression (>90%)
    ■ degenerative (disc, facet, ligament)
    ■ peripheral nerve compression (disc herniation)
    ■ spinal stenosis (congenital, osteophyte, central disc)
    ■ cauda equina syndrome
  2. others (<10%)
    ■ neoplastic (primary, metastatic, multiple myeloma)
    ■ infectious (osteomyelitis, TB)
    ■ metabolic (osteoporosis)
    ■ traumatic fracture (compression, distraction, translation, rotation)
    ■ spondyloarthropathies (ankylosing spondylitis)
    ■ referred (aorta, renal, ureter, pancreas)
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18
Q

Degenerative disc disease description

A

• loss of vertebral disc height with age resulting in
■ bulging and tears of annulus fibrosus
■ change in alignment of facet joints
■ osteophyte formation

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19
Q

Degenerative disc disease mechanism

A

compression over time with age

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20
Q

Degenerative disc disease clinical features

A
  • axial back pain without radicular symptoms
  • pain worse with axial loading and flexion
  • negative straight leg raise
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21
Q

Degenerative disc disease investigations

A

X-ray, MRI, provocative discography

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22
Q

Degenerative disc disease treatment

A

• non-operative
■ staying active with modified activity
■ back strengthening
■ NSAIDs
■ do not treat with opioids; no proven efficacy of spinal traction or manipulation

• operative – rarely indicated
■ decompression ± fusion
■ no difference in outcome between non-operative and surgical management at 2 yr

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23
Q

Spinal stenosis description

A
  • narrowing of spinal canal <10 mm
  • congenital (idiopathic, osteopetrosis, achondroplasia) or acquired (degenerative, iatrogenic – post spinal surgery, ankylosing spondylosis, Paget’s disease, trauma)
24
Q

Spinal stenosis clinical features

A
  • ± bilateral back and leg pain
  • neurogenic claudication
  • ± motor weakness
  • normal back flexion; difficulty with back extension (Kemp sign)
  • positive straight leg raise, pain not worse with Valsalva
25
Spinal stenosis investigations
CT/MRI reveals narrowing of spinal canal but gold standard = CT myelogram
26
Spinal stenosis treatment
• non-operative ■ vigorous physiotherapy (flexion exercises, stretch/strength exercises), NSAIDs, lumbar epidural steroids • operative ■ indication: non-operative failure >6 mo ■ decompressive surgery
27
Differentiating claudication
1. Aggravation Neurogenic - with standing or exercise, walking distance variable Vascular - walking set distance 2. Alleviation Neurogenic - change in position (usually flexion, sitting, lying down) Vascular - stop walking 3. Time - Neurogenic - Relief in ~10 mins Vascular - Relief in ~2 mins 4. Character Neurogenic - Neurogenic +/- neurological deficit Vascular - muscular cramping NEUROGENIC CLAUDICATION IS POSITION DEPENDENT VASCULAR CLAUDICATION IS EXERCISE DEPENDENT
28
What is mechanical back pain
back pain NOT due to prolapsed disc or any other clearly defined pathology
29
mechanical back pain clinical features
* dull backache aggravated by activity and prolonged standing * morning stiffness * no neurological signs
30
mechanical back pain treatment
* symptomatic (analgesics, physiotherapy) | * prognosis: symptoms may resolve in 4-6 wk, others become chronic
31
Lumbar disc herniation definition and usual presentation/demographic
* tear in annulus fibrosus allows protrusion of nucleus pulposus causing either a central, posterolateral, or lateral disc herniation, most commonly at L5-S1 > L4-5 > L3-4 * 3:1 male to female * only 5% become symptomatic * usually a history of flexion-type injury
32
Lumbar disc herniation clinical features
* back dominant pain (central herniation) or leg dominant pain (lateral herniation) * tenderness between spinous processes at affected level * muscle spasm ± loss of normal lumbar lordosis • neurological disturbance is segmental and varies with level of central herniation ■ motor weakness (L4, L5, S1) ■ diminished reflexes (L4, S1) ■ diminished sensation (L4, L5, S1) * positive straight leg raise * positive contralateral SLR * positive Lasegue and Bowstring sign * cauda equina syndrome (present in 1-10%): surgical emergency
33
Lumbar disc herniation investigations
• X-ray MRI, consider a post-void residual volume to check for urinary retention; post-void >100 mL should heighten suspicion for cauda equina syndrome
34
Lumbar disc herniation treatment
• non-operative ■ symptomatic ◆ extension protocol ◆ NSAIDS • operative ■ indication: progressive neurological deficit, failure of symptoms to resolve within 3 mo, or cauda equina syndrome due to central disc herniation ■ surgical discectomy
35
Lumbar disc herniation prognosis
90% of patients improve in 3 months with non-operative treatment
36
MRI abnormalities and what they mean for management of back pain
MRI abnormalities (e.g. spinal stenosis, disc herniation) are quite common in both asymptomatic and symptomatic individuals and are not necessarily an indication for intervention without clinical correlation
37
Red flags for BACK PAIN
``` BACK PAIN Bowel or bladder dysfunction Anesthesia (saddle) Constitutional symptoms/malignancy Khronic disease Paresthesias Age >50 yr IV drug use Neuromotor deficits ```
38
Types of low back pain
Mechanical back pain - disc origin - facet origin Direct nerve root compression - spinal stenosis - root compression
39
Mechanical back pain disc origin pain dominance, aggravation, onset, duration, treatment
Back Flexion Gradual Long (weeks, months) Relief of strain, exercise
40
Mechanical back pain facet origin pain dominance, aggravation, onset, duration, treatment
Back Extension, standing, walking More sudden Shorter (days, weeks) Relief of strain, exercise
41
Direct nerve root compression spinal stenosis pain dominance, aggravation, onset, duration, treatment
Leg Exercise, extension, walking, standing Congenital or acquired Acute or chronic history (weeks to months) Relief of strain, exercise + surgical decompression if progressive or severe deficit
42
Direct nerve root compression root compression pain dominance, aggravation, onset, duration, treatment
Leg Flexion Acute leg +/- back pain Short episode attacks (minutes) Relief of strain, exercise + surgical decompression if progressive or severe deficit
43
Approach to back pain etiology
Back dominant a) Constant - then inflammatory or mechanical b) Intermittent - then disc herniation (central) or facet joint Leg dominant a) constant - then disc herniation (lateral) b) intermittent - spinal stenosis
44
Sciatica description and most common cause
Most common symptom of radiculopathy (L4-S3) * Leg dominant, constant, burning pain * Pain radiates down leg ± foot * Most common cause = disc herniation
45
Spondylolysis definition
defect in the pars interarticularis with no movement of the vertebral bodies
46
Spondylolysis mechanism
• trauma: gymnasts, weightlifters, backpackers, loggers, labourers
47
Spondylolysis clinical features
• activity-related back pain, pain with unilateral extension (Michelis’ test)
48
Spondylolysis investigations
* oblique X-ray: “collar” break in the “Scottie dog’s” neck * bone scan * CT scan
49
Spondylolysis treatment
• non-operative | ■ activity restriction, brace, stretching exercise
50
ADULT ISTHMIC SPONDYLOLISTHESIS | definition
defect in pars interarticularis causing a forward translation or slippage of one vertebra on another, usually at L5-S1, less commonly at L4-5
51
ADULT ISTHMIC SPONDYLOLISTHESIS | mechanism
• congenital (children), degenerative (adults), traumatic pathological, teratogenic
52
ADULT ISTHMIC SPONDYLOLISTHESIS | clinical features
* lower back pain radiating to buttocks relieved with sitting * neurogenic claudication * L5 radiculopathy * Meyerding Classification (percentage of slip
53
ADULT ISTHMIC SPONDYLOLISTHESIS | investigations
• X-ray (AP, lateral, oblique flexion-extension views), MRI
54
ADULT ISTHMIC SPONDYLOLISTHESIS | treatment
* non-operative ■ activity restriction, bracing, NSAIDS | * operative
55
ADULT ISTHMIC SPONDYLOLISTHESIS | classification and treatment
Class 1 0-25% slip Symptomatic operative fusion only for intractable pain Class 2 25-50% Same as above Class 3 50-75% slip Decompression for spondylolisthesis and spinal fusion Class 4 75-100% Same as above Class 5 >100% Same as above
56
ADULT ISTHMIC SPONDYLOLISTHESIS Specific complications
may present as cauda equina syndrome due to roots being stretched over the edge of L5 or sacrum

Orthopedics (19 decks)

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