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MSS Weeks 3-5 > Review of functional anatomy of the spine and clinical correlations > Flashcards

Review of functional anatomy of the spine and clinical correlations Flashcards

1
Q

What are the most often identified causes for low back pain?

A
  • Intervertebral disc rupture and herniation
  • Nerve inflammation or compression
  • Degenerative changes in vertebral facet joints
  • Sacroiliac joint and ligament involvement
  • Metabolic bone disease
  • Psychosocial factors
  • Abdominal aneurysm
  • Metastatic cancer
  • Myofascial disorders
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2
Q

Symptoms of back pain?

and

Neurologic symptoms related to spinal nerve roots or cord compression?

A

* Neck, mid-back, low back pain, stiffness and loss of function

* Neurologic symptoms related to spinal nerve root(s) or cord compression:

  • Extremity pain
  • Numbness
  • Tingling
  • Weakness
  • Bowel/bladder urgency/incontinence
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3
Q

Components of musculoskeletal spine examination?

A
  1. Inspection/observation
  2. Palpation
  3. Range of motion
  4. Neuromuscular examination
  5. Special tests
  6. Examination of related areas
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4
Q

14 yo girl with flaccid paralysis limited to right arm. No pain, paresthesias, sensory loss noted. Laboratory results reveal polio virus infection. Identify the target.

and WHY

A

Ventral horn of the spinal cord gray matter

NOT

Dorsal rami of spinal nerves

Dorsal rami of spinal nerves

Ventral rami of spinal nerves

Only the ventral horn (and also ventral root) are motor. Dorsal root is sensory. All rami are mixed.

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5
Q

What is a myotome?

What is a dermatome?

A

A myotome: is a collection of muscle fibers innervated by the motor axons within each segmental nerve (root)

A dermatome: is an area of skin innervated by the sensory axons within each segmental nerve (root)

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6
Q

For dermatomes…

What types of cells?

Where do they reside?

How many pairs?

What is the top of the head dermatome?

What about the face?

A

Pseudounipolar cells

With their cell bodies residing in Dorsal Root Ganglions

31 pairs of spinal nerves

C2 innervates the top of the head because C1 contributes little to skin

Over the anterolateral head the skin is innervated by one of the three divisions of the trigeminal cranial nerve.

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7
Q

What is shingles/herpes zoster?

A

Shingles or Herpes Zoster

Is the most common infection of the peripheral nervous system.

Is an acute neuralgia confined to teh dermatome distribution of a specific spinal or cranial sensory nerve root.

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8
Q

What is the manual muscle testing scale?

A

5-Examiner cannot overcome

4-Examiner can overcome

3-No resistance

2-No gravity

1- Flicker or trace of contraction but no joint motion

0-No contraction palpated

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9
Q

Thoracic spine manual muscle testing.

A

C5- Biceps-Elbow flexor

C6-Extensor carpi radialis-Wrist extensor

C7-Triceps-Elbow extensor

C8-Flexor digitorum profundus (3rd)-Distal finger flexor

T1-Abductor digiti minimi-little finger abduction

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10
Q

Causes of muscle weakness?

A

Muscle strain

Pain/reflex inhibition

Peripheral nerve injury

Nerve root lesion (myotome)

Upper motor neuron lesion

Tendon Pathology

Avulsion

Psychologic overlay

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11
Q

Lumbar spine exam manual muscle testing

A

L2-Iliopsoas-Hip flexor

L3-Quadriceps-Knee extensor

L4-Tibialis anterior-Ankle dorsiflexor

L5-Extensor hallicus longus-Big toe extensor

S1-Gastrocnemius-Ankle plantarflexor

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12
Q

Reflex testing scale

A

Grading MSR: NINDS scale

0-absent

1-slight or less than normal (trace response or response only broughtout with reinforcement)

2-Lower half of normal (low-normal)

3-Upper half of normal (high-normal)

4- Enhanced and more than normal (inclu. clonus)

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13
Q

Cervical spine reflex testing

A

C5-Biceps

C6-Brachioradialis

C7-Triceps

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14
Q

Lumbar spine reflex testing

A

L4-Quadriceps (patellar)

L5-Medial hamstring

S1-Gastrocnemius (Achilles)

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15
Q

What are the special tests of the cervical and lumbar spine?

A

Cervical

Lhermitte’s sign

Spurling’s Neck Compression test

Hoffmann’s sign

Lumbar

Straight-leg raising test (SLR or Lasegue sign)

Femoral nerve stretch test (upper lumbar disc)

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16
Q

What is Lhermitte’s sign?

A

Passive anterior cervical flexion elicits electric-like sensation down spine or extremities, implying CERVICAL SPINAL CORD PATHOLOGY

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17
Q

What is Spurling’s Neck Compression test?

A

Reproduction of radicular symptoms with cervical spine extension, rotation, and lateral flexion.

Implies CERVICAL NERVE ROOT PATHOLOGY

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18
Q

What is Hoffmann’s sign?

A

Flick the patient’s middle finger (passive snapping flexion of middle finger distal phalanx)

Positive test is flexion-adduction of ipsilateral thumb and index finger.

Implies UPPER MOTOR NEURON PROCESS AFFECTING CERVICAL SPINE OR BRAIN

19
Q

What is the Straight-leg raising test (SLR or Lasegue sign)?

A

Patient lies supine while leg raised with knee extended. Examiner stops raising leg when patient reports pain.

Positive test is leg pain reproduced at 30-70 degrees angle.

Implies LUMBAR NERVE ROOT PATHOLOGY (L5 or S1)

20
Q

What is the Femoral nerve stretch test (upper lumbar disc)?

A

Patient placed in prone position while knee is flexed.

Positive test is reproduction of patient’s pain in anterior thigh

Implies UPPER LUMBAR NERVE ROOT PATHOLOGY (L2-L4)

21
Q

What would make you think of an UMN injury?

(Spinal cord injury, Brain injury/stroke, Myelopathy, CNS lesion)

A

Spasticity/hypertonicity

Increased reflexes (hyperreflexia)

Positive pathological reflexes

Extensor plantar response

22
Q

What should make you think of a lower motor neuron injury? Begins with the anterior horn cells of the spinal cord and includes the peripheral nerves

(Peripheral nerve entrapment, radiculopathy)

A
  1. Flaccid weakness
  2. Loss of reflexes (hyporeflexia)
  3. Muscle wasting and atrophy
23
Q

Red flags for identifying serious conditions like malignancy

A
  1. History of cancer
  2. Unexplained weight loss
  3. Age>50
24
Q

Red flags for identifying serious conditions like spinal fracture

A
  1. Major trauma
  2. Minor trauma or strenous lifting in older/osteoporotic individuals
  3. Prolonged corticosteroid use
  4. Osteoporosis
  5. Adv age > 70
25
Q

Red flags for identifying serious conditions like infection

A
  1. Constitutional symptoms (fever, chills)
  2. Recent bacterial infection (urinary tract or skin infections, pneumonia)
  3. Immunosuppression
  4. Intravenous drug abuse.
26
Q

For lumbar strains,

What is the history?

What is the etiology?

What is found on exam?

What is treatment?

A

Lumbar strain

History: Axial low back pain after acute injury like lifting or twisting;pain worse with movement;better with rest

Etiology: Muscle disruption from excessive stretch or tension

Exam: localized muscle tenderness/reduced ROM/Normal neuro exam

Treatment:

Relative rest

Pain control with NSAIDS, muscle relaxants

Physical therapy if >4 weeks or recurring

Majority self limited

27
Q

Radiculopathy, nerve root impingement

What are the most affected nerves in cervical spine and lumbar spine?

A

Cervical spine: C6, C7 most affected

Lumbar spine: L5, S1 most affected

28
Q

What are the pathophysiologies of radiculopathy?

A

Mechanical compression of nerve root

  • Neural ischemia, increased intraneural pressure
  • Edema of nerve root, DRG
  • Dura is mechanically sensitive

Biochemical irritation of nerve root

  • Nucleus pulposis contains cytokines, leukotrienes, cox2,interleukin1, tnf-alpha
  • Can cause apoptosis of DRG cells
29
Q

For Disc Herniations, what is the history?

A

Acute injury/event or more insidious. Limb pain>axial spien pain

numbness/tingling/weakness may or may not be present

Worse: lumbar- sitting, bending, cough/sneeze

Cervical- ROM

Better: lumbar- standing, walking

Cervical-lying

30
Q

What are exam findings for disc herniations?

A

Myotomal weakness

Dermatomal pain/numbness/tingling

Decreased or absent reflex of affected nerve

Spurling or SLR positive

31
Q

What are the typical treatments for disc herniation?

A

Activity modification-avoiding bedrest

Pain medication: NSAIDs, neuromodulators, short course oral prednisone, limited opioids

Physical therapy

Epidural steroid injection for pain control

*Surgical discectomy possible but 70-85% improve w/out

32
Q

What indications are there for discectomies in disc herniations?

A

Progressive or profound weakness

Refractory symptoms

Bowel/blader dysfunction

Myelopathy

33
Q

What is Ankylosing Spondylitis presentation early and late?

A

Early Ankylosing Spondylitis:

  • Widening of the sacroiliac joints with adjacent sclerosis compatible with sacroilitis
  • There is posterior longitudinal ligament sclerosis at L1-L2, L2-L3

Late Ankylosing Spondylitis:

  • Fusion of both sacroiliac joints compatible with advanced sacroilitis
  • Symmetric syndesmophytes bridging all vertebral bodies resulting in a bamboo spine
  • Ossification of the anterior, posterior, and interspinous longitudinal ligaments
34
Q

What is Ankylosing spondylitis?

A

A chronic inflammatory disease with progressive involvement of sacroilac and axial skeletal joints. Also w/ enthesitis as well as chondritis and osteitis

35
Q

For Ankylosing Spondylitis

  • Systemic effects?
  • History?
  • Exam?
  • Labs?
  • Treatment?
A

Systemic effects

Upper lobe interstitial lung fibrosis

Iritis

CV abnormalities (aortitis, aortic insuff, cardiomegaly, conduction defects)

History

Slowly progressive low back pain and stiffness. Worse in morning and with prolonged inactivity, better with exercise.

Exam

Reduced lumbar ROM, tender over SI joints, SI joint provocative tests positive. otherwise unremarkable

Labs

Elevated C-reactive protein, sedimentation rate. 90% HLA-B27 positive

Treatment:

NSAIDs/Physical therapy/Anti-TNF-alpha agents if severe and refractory to NSAIDs

36
Q

What is spondylolysis and spondylolisthesis

A

Fracture of PARS lamina with no slippage of adj articulating vertebrae (most common L5-S1)

versus

bilateral defect with complete dislocation w/anterior displacement of the L5 body and transverse process.

37
Q

What is the

History

Etiology

Exam

Treatment

For Facet joint arthropathy

A

For Facet joint arthropathy

History: Axial low back pain, gradual onset.

Cervical worse with cervical extension, lumbar worse with standing/walking (better sitting/lying)

Etiology: Gradual degen/osteoarthritis to zygoapophyseal (facet) joints. These are synovial joints and this becomes common >55

Exam: Nonspecific, pain provoked with active extension, relieved with flexion

Treatment: Imaging, NSAIDs, Physical therapy, Facet joint steroid injections if refractory

38
Q

For Lumbar stenosis

History

Exam

Etiology

Treatment

A

History: Slowly progressive pain in back and uni or bilateral legs (worse when standing/walking, relieved with lumbar flexion, sitting)> Usually >55 yo

Exam: No focal findings, neural exam normal

Etiology: Narrowing of the spinal canal

Treatment: Physical therapy, gait aid, NSAIDs, Epidural steroids, Surgical if intolerable pain

39
Q

What is the most common cause for compression fractures?

A

Osteoporosis

Assoc. with prolonged coritcosteroid use. However if <55 yrs then consider underlying malignancy such as multiple myeloma.

40
Q

For compression fractures

History

Exam

Labs

Treatment

A

History:

Sudden onset of thoracic or lumbar pain

Can be related to trauma/fall/heavy exertion, or not.

Worse with flexion and movement

Better with rest.

Usually no leg pain or tenderness.

Exam:

Local tenderness,

painful lumbar ROM (especially flexion),

normal neuro

Treatment

Imaging: plain xrays or maybe MRI or CT

If malignancy suspected: CBC, SPEP, alkphos, ESR

NSAIDs, acetaminophen, calcitonin, mild opioids

Bracing x6 weeks

Osteoporosis workup (DEXA scan, endocrine w/u)

41
Q

For Caudal Equina Syndrome

History

Etiology

Exam

Treatment

A

For Caudal Equina Syndrome

History:

Back pain

Leg pain (numbness, weakness)

Saddle anesthesia

Bowel or bladder dysfunction (urinary retention most common)

Etiology: Large herniated disc compressing cauda equina most common (can also be epidural tumor/abcess/hematoma)

Exam: Reduced or absent reflexes, weakness, decreased rectal tone

Treatment: Surgical emergency

42
Q

Findings from exam for Cervical Myelopathy

A
  • UE and LE w/ predom upper motor neuron findings and weakness below level of cord involvement (Hyperreflexia in upper and lower limbs, Hoffman’s sign/positive babinski, ankle clonus)
  • Lhermitte sign
  • Romberg sign
  • Wide base, ataxic, shuffling, slow gait
43
Q

Etiology for Cervical myelopathy

A

Spinal cord compression

Usually gradual progression due to posterior osteophyte formation, spinal stenosis

(can also occur due to tumor, abcess, hematoma, and other cord compressive lesions)

44
Q

Treatment for Cervical Myelopathy

A

Surgical treatment for cervical decompression (laminectomy), may not correct neuro deficits but will prevent progression.

MSS Weeks 3-5 (22 decks)

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