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Clin Path II > Week 9 Spinal Stenosis Ddx > Flashcards

Week 9 Spinal Stenosis Ddx Flashcards

1
Q

Diagnosis requires which 3 factors?

A
  1. Characteristic signs/symptoms
  2. Radiographic (MRI or CT) evidence of lumbar spinal stenosis
  3. Exclusion of other causes of back and leg pain
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2
Q

Ddx for patients with low back and leg pain

A

Neuropathic:

  1. Nerve root: disc herniation, SOL (tumor, cyst, hematoma), osteophyte, compression fracture, spinal infection
  2. Peripheral neuropathy: piriformis syndrome, diabetes, herpes zoster, compartment syndrome, peroneal nerve compression

Referred:
- facets, deranged disc, MFTP, trochanteric bursitis, hip OA

  • PAD, medial tibial stress syndrome, stress fracture of tibia or fibula, muscle strain
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3
Q

At what age is spinal stenosis at the top of the ddx for neuropathic leg pain?

A

> 60

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4
Q

Stenosis occurs in
__% of patients ___ -___ y.o. with leg pain
____% of patients >___ y.o. with leg pain

A

25%, 60-70

64%, >70

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5
Q

What are other ddx for patients over 60 with neuropathic pain? (A list and B list)

A

A list

  • IVF encroachment (osteophyte secondary to DJD)
  • SOL (cancerous tumor, less likely cyst)

B list

  • radicular: degenerative spondylolisthesis, structural instability, spinal infection
  • peripheral: diabetic, other peripheral neuropathy, piriformis syndrome
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6
Q

What are causes of IVF encroachment?

A

Spur/osteophyte

IVF stenosis

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7
Q

What are signs and symptoms of IVF encroachment? (4)

A
  • no neurogenic claudication or CES symptoms
  • often unilateral, sometimes a single dermatome
  • positive kemp’s with pain into leg (suggest IVF is compromised)
  • may not be as sensitive to pure flexion or extension loads
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8
Q

How do you ddx spinal stenosis from spur/osteophyte?

A

Advanced imaging

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9
Q

Tumor (especially malignant) are more likely in patients ___

A

> 50

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10
Q

What are signs/symptoms of tumor

A
  • neurological deficits or cord signs (long track) may be present
  • sometimes leg pain is accompanied by little or no back pain
  • spinal percussion may be very sensitive
  • may have classic red flags
  • positive lab and imaging tests
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11
Q

What should you be concerned about in a patient >50 with leg pain and no back pain

A

Tumor

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12
Q

What are red fags for tumor

A
  • prior history of cancer
  • unexplained weight loss
  • increase pain when lying supine
  • unremitting pain affected by spinal positioning
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13
Q

What are positive ab findings for tumors?

A
  • anemia
  • increased ESR/CRP
  • increase ALP (metastatic prostate cancer, osteoblastic cancer)
  • proteins (on blood chem panel, multiple myeloma)
  • hypercalcemia (osteolytic like metastatic breast cancer)
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14
Q

Spinal infections are very rare in the (long bones/spine?) and occur more in the (long bones/spine?)

A

Very rare in spine

More in long bones and extremities

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15
Q

What age are spinal infections most common?

A

> 50

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16
Q

What are some signs/symptoms of spinal infection? (6)

A
  • rapid or but usually slow indolent course
  • prior history of infection (kidney/bladder infection) or immune compromised patient
  • may run fever (65% of cases)
  • usually very sensitive to spinal percussion (90% of cases)
  • very high ESR (>50-100) ver common (80-90% of cases)
  • may have neuro deficits. Positive tension tests
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17
Q

What is the top of ddx list for neuropathic pain in patients <40? What are other causes?

A
  • Disc herniation
  • radicular: spondylolysis/spondylolisthesis, structural instability, spinal infection, nerve root adhesions, fracture, spinal stenosis
  • peripheral: diabetic, other peripheral neuropathy, piriformis syndrome
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18
Q

spinal stenosis vs disc herniation: age

A

> 50-60

<40-50

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19
Q

spinal stenosis vs disc herniation: flexion load

A
  • may improve leg symptoms (shopping cart sign)

- may increase leg symptoms

20
Q

spinal stenosis vs disc herniation: sitting

A
  • improve leg symptoms

- increase leg symptoms (may be rapid)

21
Q

spinal stenosis vs disc herniation: sustained/repetitive loading?

A
  • may aggravate leg symptoms if done in extension

- may centralize or improve leg synths (done in any direction, although extension is most common)

22
Q

spinal stenosis vs disc herniation: extension loads?

A
  • may aggravate back or legs

- may aggravate back (and could improve leg symptoms)

23
Q

spinal stenosis vs disc herniation: valsalva, dejerine’s triad

A
  • negative

- positive (aggravating back or legs)

24
Q

spinal stenosis vs disc herniation: axial compression (double ASLR)

A
  • less likely to be positive

- more likely to be positive (especially if acute)

25
Q

spinal stenosis vs disc herniation: SLR ( and other nerve tension tests)

A

Rarely positive

Usually positive for leg symptoms (80-90% of cases)

26
Q

spinal stenosis vs disc herniation: neuro deficits

A
  • in about 50% of cases

- more frequent (80% of cases)

27
Q

spinal stenosis vs disc herniation: ataxia

A
  • wide stance/gait, positive Romberg may be present

- normal

28
Q

spinal stenosis vs disc herniation: CES

A

VERY RARE IN BOTH but possible (both are one of the leading cases of CES)

29
Q

What is the term for leg pain with walking? What are the top three causes and what is the medical term for each?

A
  • intermittent claudication
  • Stenosis (neurogenic claudication)
  • PAD (vascular claudication)
  • other (e.g. hip lesion)
30
Q

Stenosis vs PAD: location?

A
  • thigh

- calf/lower leg

31
Q

spinal stenosis vs disc herniation: muscle strength after walking

A
  • increased muscle weakness

- unchanged

32
Q

spinal stenosis vs disc herniation: palliative factors

A
  • Bending or sitting

- sitting, stop walking

33
Q

spinal stenosis vs disc herniation: how much time they can walk before pain

A
  • variable

- consistent

34
Q

spinal stenosis vs disc herniation: provocative factors

A
  • waking downhill, increased lordosis

- walking uphill, increased metabolic demand

35
Q

spinal stenosis vs disc herniation: lower extremity pulses

A
  • present

- absent

36
Q

spinal stenosis vs disc herniation: van Gelderen bicycle test

A
  • no leg pain

- leg pain

37
Q

spinal stenosis vs disc herniation: shopping cart sign

A
  • present

- absent

38
Q

PAD vs DVT: pain at rest

A
  • made worse by walking, especially uphill, only night/rest pain when severe (may require opiates as analgesic agents):
  • pain at rest
39
Q

PAD vs DVT: swelling

A
  • no swelling

- swelling of the lower limbs and may be red

40
Q

PAD vs DVT: temperature

A
  • reduced skin temperature (if anything)

- increased temperature

41
Q

PAD vs DVT: observational changes

A
  • tissue loss (ulceration); muscle wasting; loss of hair; dry; thin; brittle nails
  • dilation of superficial veins
42
Q

PAD vs DVT: palpation

A
  • pulses are diminished or absent, presence of bruits

- palpable tender, hard “cord” along the vein

43
Q

With a suspected spinal stenosis, do a basic low back physical exam and (4 things)

A
  • sustained extension (30-60 seconds, especially if extension did not bother the patient)
  • repeat neurological exam after patient walks to point where they get symptoms
  • Romberg test
  • check lower extremity pulses
44
Q

Ancillary studies for stenosis

A
  • radiograph (looking for degeneration such as disc thinning, facet thickening, spur) (used to R/O infection, tumor, spurs in IVF) (not enough to make the diagnosis

confirm with MRI (or sometimes CT)

  • relative lumbar spinal stenosis = narrowing =12mm diameter
  • absolute lumbar spinal stenosis = narrowing = 10mm diameter

If they need surgery: electromyoraphic paraspinal mapping (needle EMG on paraspinal muscle to map which muscles are involved and to what degree nerve action potentials are affected.

45
Q

Ancillary studies for PAD (vascular claudication)

A
  • duplex/Doppler ultrasound (looking at blood flow)
  • ankle-brachial index (ABI) (<0.90) (blood pressure with ultrasound, to see blood flow in lower extremity vs upper
  • MRA (angiography) = GOLD STANDARD
46
Q

In a patient who had both stenosis and PAD, what ancillary test is required to tell which condition is causing their symptoms

A
  • treadmill test with an incline
  • stenosis patient can walk further without pain because the spine is flexed
  • PAD patient unable to walk as far (because of increased muscle oxygen demand)
47
Q

Conservative PAD management

A
  • walking “near pain threshold” (or into the pain) at least 3x/week (supervised walking programs are more effective)
  • lifestyle changes to support cardiovascular health: stop smoking, improve diet (e.g. Mediterranean)
  • toe raises 3x/day. Do reps until there is pain and then 5 more

Clin Path II (18 decks)

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