18: Basic Exam for spine

Question 1

History of cancer and/or Unexplained weight loss -

Answer 1

– r/o malignancy

Question 2

Loss of bowel or bladder control – r/o

Answer 2

r/o myelopathy or stenosis

Question 3

Significant weakness in spine r/o

Answer 3

– r/o myelopathy or radiculopathy

Question 4

Saddle anesthesia – r/o

Answer 4

myelopathy or cauda equina syndrome

Question 5

Chronic corticosteroid use – r/o

Answer 5

compression fracture

Question 6

Pt that has Immunosuppression and or fever – r/o

Answer 6

infection

Question 7

IV drug use and back pain – r/o

Answer 7

infection

Question 8

Pt with back pain and Prior spine surgery – r/o

Answer 8

hardware failure, adjacent segment disease, recurrent disc

herniation

Question 9

A patient has back Weakness and/or numbness –

we should be suspicious for

Answer 9

nerve involvement

Question 10

Pt has Morning stiffness, improves with activity but not with rest (<40 yo) – suspicious for

Answer 10

spondyloarthropathy

Question 11

fracture of the pars interarticularis

Answer 11

Spondylolysis

Question 12

anterior displacement of one vertebrae on another

Answer 12

Spondylolisthesis

Question 13

a. Hyoid bone –
b. Thyroid cartilage –
c. First cricoid ring –
d. Most prominent spinous process –

Answer 13

C3
C4-5
C6
C7

Question 14

Top of iliac crest located at

Answer 14

L4-5

Question 15

Posterior superior iliac spine located at

Answer 15

S2

Question 16

Expected ROM of Cervicle spine

1. Rotation:
2. Flexion:
3. Extension:
4. Sidebending:

Answer 16

Cervical spine

1. Rotation – ~70°
2. Flexion – ~45° (chin to chest)
3. Extension – ~55°
4. Sidebending – ~40°

Question 17

Lumbar spine

1. Flexion –
2. Extension –
3. Lateral bending
4. Rotation

Answer 17

Lumbar spine

1. Flexion – ~75°
2. Extension – ~30°
3. Lateral bending – ~35°
4. Rotation

Question 18

passive rapid flexion of middle finger distal phalynx. Positive test is flexion of thumb, index finger

Answer 18

Hoffman – signs of Upper Motor Neuron Lesion

Question 19

stroking sole of foot resulting in great toe extension and toe
spreading

Answer 19

Babinski– signs of Upper Motor Neuron Lesion

Question 20

Straight leg raise (SLR) – lying supine, leg is raised with knee extended. Positive test is

Answer 20

reproduction of radicular symptoms with hip flexed between 30-70°

Question 21

Femoral stretch test – lying prone, knee is flexed to 90° and thigh elevated. Positive test is

Answer 21

reproduction of anterior thigh radicular symptoms

Question 22

Spurling – reproduction of ipsilateral radicular symptoms with cervical spine extension, rotation, lateral sidebending This test suggests

Answer 22

cervical nerve root involvement

Question 23

Lhermitte – electrical shock sensation in limbs with cervical flexion suggests

Answer 23

cervical cord involvement

Question 24

Pt comes in with axial low back pain after acute injury, such as lifting or twisting

Answer 24

Lumbar strain

Question 25

Causes of lumbar strain

Answer 25

muscle disruption from excessive stretch or tension

Question 26

During exam, pt experiences localized muscle tenderness, reduced ROM in their spine

Answer 26

lumbar strain

Question 27

What imaging would we get for suspected lumbar strain?

Answer 27

usually none.

Question 28

Tx for Lumbar Strain

Answer 28

Relative rest, NSAIDs, muscle relaxant, physical | therapy

Question 29

Pt complains axial low back pain, gradual onset (cervical: worse with cervical extension; lumbar: worse standing/walking, better sitting/lying)

Answer 29

Osteoarthritis

Question 30

Etiology of osteoarthritis

Answer 30

gradual degenerative changes/osteoarthritis to zygoapophyseal (facet) joints; more common age > 55

Question 31

Expected Exam findings in patient with osteoarthritis worse with: better with:

Answer 31

nonspecific, pain provoked with active extension, relieved with flexion

Question 32

Treatment for OA–

Answer 32

``` NSAIDs, mild analgesics. Physical therapy (flexion bias), possibly facet joint injections ```

Question 33

What imaging would we want to order for expected OA?

Answer 33

Imaging: none or plain lumbar x-rays.

Question 34

Patient experiences pain and possible numbness/weakness in limb > axial spine Lumbar: worse sitting/flexion, better standing/extension

Answer 34

Radiculopathy

Question 35

most common cause of radiculopathy

Answer 35

disc herniation

Question 36

Expected exam findings of patient with radiculopathy?

Answer 36

SLR or Spurling positive, neurologic deficits (myotomal weakness, decreased reflex, dermatomal reduced sensation)

Question 37

Imaging ordered for suspected radiculopathy:

Answer 37

MRI, possible EMG.

Question 38

Tx for patient with radiculopathy

Answer 38

Relative rest, physical therapy, surgical discectomy if progressive/severe weakness or unresponsive to conservative care. For pain, NSAIDs, oral or epidural corticosteroids, limited opioids, neuromodulators

Question 39

Pt comes in with slowly progressive back and unilateral or bilateral leg pain. It is worse when standing, and better when sitting. Positive for shopping cart sign (bc flexes spinal canal)

Answer 39

Lumbar stenosis

Question 40

You suspect your patient to have lumbar stenosis, what are the key DDx?

Answer 40

Differentiate from vascular claudication (must sit | or bend to relieve symptoms)

Question 41

Causes of Lumbar Stenosis

Answer 41

narrowing of the spinal canal (due to disc herniation/ protrusion, ligamentum flavum thickening, osseous thickening of bone/facet joint, spondylolisthesis)

Question 42

Imaging ordered for suspected Lumbar Stenosis

Answer 42

Imaging: MRI, possibly CT or EMG.

Question 43

Treatment for Lumbar Stenosis

Answer 43

NSAIDs, neuromodulators, physical therapy (flexion bias), use of walker, epidural steroids, surgery for lumbar decompression

Question 44

Patient comes in with back pain, numbness, weakness in arms and/or legs; balance and gait difficulties; bowel/bladder dysfunction

Answer 44

cervical myelopathy

Question 45

Etiology for suspected cervical myelopathy

Answer 45

cervical canal stenosis with spinal cord compression

Question 46

On exam, patient has arm and/or leg weakness, upper motor neuron signs-- hyperreflexia, Hoffman/Babinski, ataxia, and increased tone

Answer 46

Cervical myelopathy

Question 47

Treatment options for Cervical Myelopathy

Answer 47

Surgical decompression. No role for nonoperative | treatment

Question 48

What imaging would you order for suspected cervical myelopathy?

Answer 48

MRI

Question 49

Old patient comes in with sudden thoracic (or lumbar) pain with no history of trauma. On exam they are tender over spinous processes, paraspinals. Worse: lumbar flexion. Better: lumbar extension. Normal neuro exam (unless nerve root affected)

Answer 49

Compression fracture

Question 50

Causes of Compression fracture in spine

Answer 50

ii. Etiology – majority related to osteoporosis, older patients; anterior vertebral body wedge fracture. T10, T11, T12, L1 most commonly. In younger patients w/o clear etiology, consider malignancy, multiple myeloma. 1/3 are asymptomatic

Question 51

Patient comes in with suspected comression fracture of spine. What imaging do you order?

Answer 51

plain x-rays, possibly MRI or CT; DEXA scan to eval for osteoporosis. If malignancy considered: CBC, SPEP, alkaline phosphatase, sed rate (malignancy for our younger pts)

Question 52

Tx options for

Answer 52

NSAIDs, acetaminophen, calcitonin, mild opioids. Consider bracing for 6 weeks. Physical therapy. Symptoms usually improve in 3 months. Vertebroplasty/kyphoplasty a consideration, evidence of efficacy limited

Question 53

Pt comes in with onset of low back pain < age 40, insidious, better with exercise, pain at night and on waking, not improved with rest

Answer 53

Ankylosing spondylitis

Question 54

Suspected etiology of Ankylosing spondylitis

Answer 54

inflammatory spondyloarthropathy, usually sacroiliitis initially. Can be associated with uveitis, inflammatory bowel disease, psoriasis among other features

Question 55

On exam, patient i has reduced

Answer 55

Reduced lumbar ROM, often tender to palpation over sacroiliac joints with positive joint provocative tests (FABER, Gaenslen).

Question 56

You suspect a patient of having ankylosing spondylitis. What imaging would you order? Early? Late? Labs?

Answer 56

plain x-rays – earliest finding sacroiliitis. | Later syndesmophytes can progress to “bamboo spine”. Labs: HLAB27, C-reactive protein, sed rate.

Question 57

Tx options for patient with ankylosing spondylitis?

Answer 57

NSAIDs – typically marked relief. Consider anti-TNF agents. | Physical therapy, emphasis on spine extension

Question 58

Pt comes in and complains of leg pain, numbness, weakness; saddle anesthesia; bowel/bladder dysfunction (urinary retention most common; urinary or stool incontinence). Dx?

Answer 58

Cauda equina syndrome

Question 59

Etiology of patient with cauda equina syndrome

Answer 59

large herniated disc compressing cauda equina most common (also epidural tumor, abscess, or hematoma)

Question 60

What exam findings would you expect to see in someone with cauda equina syndrome?

Answer 60

reduced or absent reflexes, weakness, decreased rectal tone

Question 61

Tx for cauda equina syndrome?

Answer 61

Surgical emergency