Orthopedics - R > Back Disorders > Flashcards

Back Disorders Flashcards

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1
Q

Define the following:

  1. Lordosis?
  2. Kyphosis?
  3. Scoliosis?
A
  1. Lordosis - increased anterior convexity in the curvature of the spine
  2. Kyphosis - exaggeration of posterior convexity of the thoracic vertebral column found commonly with OA and osteoporosis.
  3. Scoliosis - lateral curve of the spine usually right convex thoracic, most of, which are idiopathic
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2
Q
  1. What is spondylolisthesis?
  2. Stenosis?
  3. Spondylolysis?
A
  1. Spondylolisthesis - Anterior slip, bilateral pars defect, congenital usually L5 on S1, degenerative L4 on L5 - palpable step off with or without neurological symptoms
  2. Stenosis - narrowing of the spinal canal or neural foramen producing root ischemia or neurogenic claudication.
  3. Spondylolysis - stress fracture of pars interarticularis
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3
Q

Physical Exam of LB should include?

5

A
  1. Note curves of spine, posture, uneven height of iliac crests
  2. ROM - flexion, extension, sidebend, and rotation
  3. Palpation of spinous processes - prominence especially of L4-L5 in relation to another indicates potential spondy
  4. Paravertebral palpation
  5. LE ROM - decreased IR/ER or reproduction of pain may indicate hip joint pathology
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4
Q

Nerve Root Distribution of the Lumbar Spine

  1. How should we test L1-L2-L3?
  2. Muscle test for hip flexion/testing what?
  3. Sensory is where?
A
  1. L1-L2-L3 no individual reflex, muscle and sensory testing only.
  2. Muscle test - hip flexion = iliopsoas
  3. Sensory - area between inguinal ligament and above patellae.
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5
Q

L4

  1. Reflex?
  2. Muscle test?
  3. Dorsiflexion?
  4. Sensory?
A
  1. Reflex - Patellar
  2. Muscle test - Ankle
  3. Dorsiflexion = Anterior Tibialis
  4. Sensory - Medial foot and leg
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6
Q

L5

  1. Reflex?
  2. Muscle test?
  3. Sensory?
A
  1. Reflex - none
  2. Muscle test - great toe extension = Extensor hallucus longus
  3. Sensory - lateral leg and dorsum of foot
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7
Q

S1

  1. Reflex?
  2. Muscle test?
  3. Sensory?
A
  1. Reflex - Achilles
  2. Muscle test - ankle eversion = peroneus longus and brevis
  3. Sensory - lateral foot
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8
Q

Low Back Pain

  1. What vertebrae are the largest and strongest?
  2. Intervertebral disc lies between 2 _______ vertebrae?
  3. Disc is composed of what? 2
  4. The function of the disc is what?
A
  1. Lumbar
  2. adjacent

3.

  • nucleus pulposus (central gelatinous portion)
  • enclosed in several layers of fibrocartilaginous laminae (annulus).
    4. to provide cushion and facilitate movement in the spine.
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9
Q
  1. What is the ALL ligament?
  2. PLL?
  3. What connects the spinous processes? 2
A
  1. ALL - Broad sheath of connective tissue along with the anterior surface of vertebral bodies.
  2. PLL - Lies along the posterior surface of vertebral bodies inside the vertebral canal.
  3. Interspinous and supraspinous - connect spinous processes.
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10
Q

Lower back pain: Musculature innervated by?

Enclosed by what?

A

Innervated by dorsal rami of spinal nerves and are enclosed by fascia.

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11
Q
  1. Muscles of the spine attach to the what? 2
  2. Superior and inferior articulating processes articulate with vertebrae above and below to create what on either side of the spine?
  3. Openings between 2 adjacent vertebrae is the intervertebral foramen which forms the what?
A
  1. spinous and transverse processes
  2. facet joint
  3. the spinal canal, the passage of the spinal nerves occurs here
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12
Q

Dx tests for lower back pain?

6

A
  1. plain radiograph
  2. Bone scan
  3. Diskography
  4. CT myelogram
  5. MRI
  6. Labs
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13
Q

NEVER GET CONTRAST ON THE SPINE UNLESS?? 3

A
  1. Tumor
  2. Infection
  3. Recurrent heriated disc
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14
Q
  1. What plain radiographs angles will you get and if what?
  2. What can this show? 5
  3. What will a bone scan rule out? 2
  4. Diskography is for what?
  5. CT myelogram is useful when?
  6. MRI most useful for what? 2
  7. Which labs and for who? 2
A
  1. Plain radiographs - AP and Lateral along with A/P pelvis and lateral hip on affected side.
  2. Visualize
    - compression fractures,
    - DDD,
    - scoliosis,
    - spondy,
    - hip OA i.e. bony deformities.
  3. Bone scan -
    - Rule out infection,
    - occult metastatic tumor.
  4. Diskography - surgical purposes only- determines level of pain source.
  5. CT Myelogram - accurate assessment of stenosis.
  6. MRI - most useful for
    - disc injury,
    - road map for surgery
  7. Labs - High risk patients or unimproved after 8-12 weeks of conservative treatment.
    - CBC and
    - Sed Rate to rule out infection, tumor.
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15
Q

Hernaited Disk

  1. A herniated disk fragment comes from the what?
  2. In the normal condition, this nucleus is in the disk center securely contained by what?
  3. When a fragment of nucleus herniates, it does what?

A
  1. nucleus pulposus of the disc.
  2. the annulus fibrosus.
  3. irritates and/or compresses the adjacent nerve root.
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16
Q

Herniated disks

  1. This can cause the pain syndrome known as what?
A
  1. sciatica and, in severe cases, dysfunction of the nerve.

Almost 5% of males and 2.5% of females experience sciatica at some time in their lifetime.

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17
Q

Herniated disk

  1. Symptoms?
  2. Radiation?
  3. Level of pain depends on what?
A
  1. Symptoms – disk herniations can or cannot be associated with some degree of back pain.
  2. Pain usually radiates into the leg.
  3. Level of leg pain/radiculitis usually depends on level of disk involvement.

may be characterized as less achy, burning, or similar to an electrical shock and is often described as a shooting or stabbing pain

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18
Q

Herniated Disk

  1. Which area?
  2. Causes what kind of pain?
  3. The pain usually improves how?
  4. What sensation also occurs with the pain?
A
  1. L5-S1, which occurs most commonly,
  2. causes lateral and posterior thigh and leg pain.
  3. The pain usually improves when the patient is in the supine position with the knee bent
  4. Numbness or tingling occurs with a distribution similar to the pain.
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19
Q

Herniated Disk

  1. On examination, patients may be neurologically normal, or may have a profound what?
  2. What sign is almost always present for lower levels of herniated disk?

Whats more predictive of a lumbar hernaited disc?

  1. Gait is often abnormal. Muscle weakness may be revealed particularly when testing what?
A
  1. radiculopathy
  2. A positive straight-leg raising sign is almost always present for lower levels. However, a crossed straight-leg raising sign may be even more predictive of a lumbar disc herniation.
  3. walking on heels and toes.
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20
Q

Hernaited disks

  1. Imaging?
  2. What could be missed with this imaging?
  3. Tx?
A
  1. Imaging – MRI is most useful.
  2. However, far lateral recess disk herniation can be missed with MRI.
  3. Treatment for most disk herniation consist of conservative care vs. surgical management.
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21
Q
  1. Describe conservative care for hernaited disks?
  2. What can you use for meds? 4
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A
  1. Conservative care – consists of physical therapy in conjunction with

2.

  • NSAIDS or
  • oral steroid medication
  • muscle relaxants.
  • Can use epidural steroid injections.

Most cases will resolve with conservative treatment. Try to avoid prolonged narcotic, muscle relaxant, or steroid use.

22
Q

Herniated disks

When would you do surgery?

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A
  1. Patient presenting with cauda equina syndrome or profound motor deficits.
  2. A patient demonstrating progressive neurologic deficit during a period of observation.
  3. A patient with persistent bothersome sciatic pain, despite conservative management, for a period of 6-12 weeks.
23
Q
  1. What is spinal Stenosis?
  2. What kind of hypertrophy? and where? 4
  3. Narrowing is where?
  4. Can be caused by secondary etiologies like?4
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A
  1. Spinal canal narrowing with possible subsequent neural compression.
  2. Facet hypertrophy of the
    - vertebra,
    - vertebral body osteophytes,
    - ligamentum flavum hypertrophy
    - disc degeneration
  3. Narrowing is at the disc space
  4. Can be caused from secondary etiologies as well –
    - neoplasm,
    - acromegaly,
    - pagets disease,
    - ankylosing spondylitis.
24
Q
  1. Spinal stenosis: AKA?
  2. NC pain is exacerbated by what? 2
  3. Alleviated by? 2
  4. NC, unlike vascular claudication, is not exacerbated with what? 3
  5. Not alleviated by what?
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A
  1. Bilateral neural claudication (NC).
  2. NC pain is exacerbated by
    - standing erect and
    - downhill ambulation and is
  3. alleviated with
    - lying supine and
    - forward flexion.
  4. NC, unlike vascular claudication, is not exacerbated with
    - biking,
    - uphill ambulation, and
    - lumbar flexion and
  5. is not alleviated with standing.
25
Spinal Stenosis: 1. Main Exam findings? 4 2. Other positive findings? 2
1. Exam – pain with extension that is relieved with flexion. 2. Radiculopathy may be noted with 3. motor, sensory, and/or 4. reflex abnormalities. Other positive findings include 1. loss of lumbar lordosis and 2. forward-flexed gait.
26
Spinal Stenosis 1. Imaging? 3 2. Dx of choice? 3. Tx? 2
1. - Imaging – basic radiographs - MRI – imaging of choice\*\*\* - Vascular studies – if unsure or if confounding findings. 2. - Treatment -- physical therapy stressing good spinal flexion. Maintain fitness level. - Surgery usually some form of laminectomy.
27
1. What is degernative disc disease? 2. What makes you more at risk? 3 3. Where is the pain generally felt? 2 4. What will cause pain to increase? 5. How would we evaluate this patient? 3
1. Disc dries out and loses shock absorption effect, 2. physiologic event modified by - trauma, - heredity, - smoking. 3. Pain is usually felt in the lower back and one or both buttocks. 4. Mechanical activity will cause pain to increase. 5. Evaluation - Pain and decreased range of motion with performing flexion and extension of the spine in standing position. - Normal neurological exam and SLR, not reproducible with hip rotations. - Radiographs including AP and Lateral lumbar spine indicate disc space narrowing at single or multiple levels.
28
Degenerative Disc Disease Management? 3
1. NSAID, 2. back education program 3. Refer to MRI examination if symptoms not controlled with above or if neurological symptoms develop. no narcotics
29
1. What is facet syndrome? 2. Dx? 3. Tx? 4. Tx for intractable pain?
1. DJD of articulating surfaces of vertebrae. Similar findings of DDD. 2. This is a radiographic diagnosis. PE is same as for DDD 3. NSAID, back education program, no narcotics. Refer to MRI examination if symptoms not controlled with above or if neurological symptoms develop. 4. Focal injections into the facet joint or nerve obliteration are invasive treatments for intractable pain.
30
Muscle Sprain/Strain 1. Caused by what? 2. Pain lasts how long? 3. Pain presents how? 4. Evaluation? 3 5. Managment? 3 6. Refer when?
1. Caused by repetitive lifting, bending or other trauma. 2. Pain lasts days to weeks. 3. Pain is usually localized without radicular symptoms or neurological findings. 4. Evaluation - - specific muscular tenderness and reproducible pain with muscle testing or movement. - Inflamed and swollen muscle. - Radiographs are normal. Normal neurological exam, 5. Management - - NSAID, - Back education pain, - relative rest with activity modification. 6. Refer if not better after 4-6 weeks of adhering to the above regimen.
31
Cauda Equina Syndrome 1. Cause? 3 2. Common complaint? 3. Evaluation? 3 4. Management?
1. Mechanism is usually - trauma, - spinal cord injury, - compression of sacral nerve roots. 2. \*Urinary retention with neurogenic bladder 3. Evaluation - - Rectal tone, - bulbocavernosus reflex S1,S2,S3., - sacral sparing evaluating perianal sensation 4. Management - Refer immediately - EMERGENT
32
Ankylosing spondylitis 1. Classified how? 2. Has a predilection for what? 3 3. Characteristics of the dz? 2 4. This tissue replaces the disk fibers with what?
1. Ankylosing spondylitis usually is classified as a chronic and progressive form of seronegative arthritis. 2. has a predilection for the - axial skeleton, - affecting particularly the sacroiliac and - spinal facet joints 3. - Formation of bony bridges between adjacent vertebrae, and - progressive ossification of extraspinal joint capsules and ligaments. 4. This tissue replaces the disk fibers with new bone.
33
Ankylosing spondylitis 1. Approximately 90-95% of patients with ankylosing spondylitis have the tissue antigen 2. Gender and Age of patient?
1. human leukocyte antigen B27 (HLA-B27): strong genetic influence exists. Family history of the disease is common. 2. - Young males typically are affected. - Peak age of onset is in patients aged 15-35 years.
34
Ankylosing spondylitis 1. Most common presenting symptom? 2. Pain is where? (centered where (1) and radiates where (2)? 3. The typical pt is who?
1. The most common presenting symptom is low back pain. 2. - pain is centered over the sacrum and - may radiate to the groin and buttocks 3. The typical patient is a young man who has repeated episodes of back pain waking him at night and associated with spinal stiffness in the morning.
35
Ankylosing spondylitis 1. What is the earliest objective sign of spinal involvement? 2. What happens when the costovertebral joints become involved? 3. Sacroilitis may be encountered how?
1. Loss of lateral flexion of the lumbar spine is the earliest objective sign of spinal involvement 2. Chest expansion becomes restricted 3. Sacroiliitis may be detected by encountering a tenderness response during percussion over the sacroiliac joints.
36
Ankylosing spondylitis 1. Radiographs reveal what? 2. Labs? 2 3. Tx? 4. Meds?
1. Radiographs reveal “bamboo spine” 2. May have elevated sed rate with a positive HLA B-27. 3. Treatment -- Regular lifelong exercises are the mainstay of the treatment program. 4. nonsteroidal anti-inflammatory drugs should be administered.
37
Compression fractures 1. Most commonly occurs in who? 2. Most commonly compression fractures cause what? 3. Can be severe resulting in what?
1. Can occur with acute trauma, but most commonly occur in the osteoporotic elderly population. 2. Most commonly compression fractures cause a “wedge” shape of the vertebrae. 3. Can be severe resulting in a burst fracture.
38
1. What is the hallmark symptom of lumbar compression fractures? 2. Describe the pain (location, radiaton, quality, severity) 3. What are important signs of neurologic injury from the fracture?
1. Midline back pain is the hallmark symptom of lumbar compression fractures 2. pain is axial, nonradiating, aching, or stabbing in quality and may be severe and disabling. 3. Reports lower extremity weakness or numbness are important signs of neurologic injury from the fracture
39
Compression Fractures 1. Compression fractures are often diagnosed when an elderly patient presents with symptoms such as? 3 2. Often, the compression fracture is the presenting symptom or finding that leads to the diagnosis of what?
1. - progressive scoliosis or - mechanical lower back pain and - the clinician obtains routine lumbar radiographs. 2. malignancy.
40
Compression fracture 1. What is essential? 2. Typically has what kind of posture? 3. This is caused by what? 4. Palpation is important to correlate any reports of pain to the what?
1. Detailed neurologic examination is essential 2. Typically has a kyphotic posture that cannot be corrected. 3. The kyphosis is caused by the wedge shape of the fracture, essentially turning squares to triangles. 4. radiographic level of injury.
41
1. Dx for Comrpession fracture? 2 2. Tx?
1. - Imaging – Ap/lateral radiographs. - MRI – can help determine an acute compression fracture from an old stable compression fracture. 2. Treatment – can be both conservative or surgical depending on the amount of compression, and/or any burst elements.
42
Compression Fracture 1. Surgical intervention/referral if compression results in greater than \_\_\_\_% of the vertebral height and is associated with what? 2. Conservative treatment consists of what? 3
1. 30, significant pain. 2. - bracing, - analgesic medications - rest
43
Scoliosis 1. Cause? 2. Definition? 3. How is it found?
1. Cause has been postulated to be genetic in nature. 2. Causes lateral curvature of the spine, greater than 10 degrees away from the central axis 3. The “curve” is found without presenting pain, rarely if ever painful
44
Scoliosis 1. Dx? 2 2. Most common curve? 3. Common tx algorithm? 2
1. - Forward Flexion test - High sided scapula/shoulder 2. Most common curve is right thoracic 3. Common treatment algorithm: - Curves less than 25 degrees, observe with serial x-rays overtime. - Bracing for rapidly progressing curves to 20-25 degrees or greater
45
Scoliosis 1. Bracing for who? 2. Surgical tx for who? 3. What is a measure of the resulting scoliosis angle based on radiographs?
1. Bracing for curves 20-40 degrees 2. Surgical treatment for “inflexible” curves over 40 degrees and essentially any curve over 50 degrees 3. Cobb angle – A measure of the resulting scoliosis angle based on radiographs.
46
What do we measure in the Cobb Angle?
Cobb angle measure the most tilted one up and the most tilted one down
47
Local Pain 1. Acute or chronic? 2. Quality of the pain? 3. Region? 4. Radiation? 5. Pain often precipitated or aggrevated by what? 6. Relived by? 7. What is typically limited by pain?
Local pain - common LBP. 1. Acute, often recurrent or chronic 2. aching pain in the 3. L-S region possible 4. radiating to buttocks not below knees. 5. Pain often precipitated or aggravated by moving, lifting, or twisting motions and 6. relieved by rest. 7. Spinal movements typically limited by pain.
48
Radicular Pain 1. Pain usually superimposed on what? 2. Quality of the pain? 3. Radiation? 4. Associated with what? 2 5. Usually worsened by what?
Radicular (nerve root) pain 1. usually superimposed on LBP. 2. Sciatic pain is shooting and 3. radiates down one or both legs usually below knee or knees in a dermatonal distribution often with 4. associated - numbness and tingling - possible local weakness. 5. Pain usually worsened by spinal movements such as forward flexion, sneeze, cough or strain.
49
Referred Pain 1. Quality of pain? 2. Spinal movments and ROM affect this how? 3. Look for signs of a primary disorders such as? 6 4. This involved a much more complete exam including what? 5
1. Usually deep aching pain level of which varies with the source. 2. Spinal movements are not painful and ROM does not reproduce pain. 3. Look for signs of primary disorder i.e. - PUD, - pancreatitis, - prostatitis, - bladder infection, - endometriosis, - AAA. 4. This involved a much more complete exam including - CVA, - pelvic exam, - urine dip, - abdominal and cardiac exam, - prostate and rectal exam.
50
When would you consider metastatic malignancy in the spine from prostate, bladder, kidney, breast, lung? This requires thorough history and physical pain 3
1. Nocturnal (Aching) back pain 2. unrelieved by rest. 3. Local bone tenderness.
51
Read Slides 64-72
Read slides 64-72
52
S/S of Life Threatening Proportion 5
1. Aching nocturnal pain unrelieved by rest 2. S/S AAA 3. B/B incontinence 4. Cauda Equina 5. Spine fracture with instability
Orthopedics - R
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