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102 Cards in this Set
- Front
- Back
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Name the parts of the somite and what they develop into. (Embryology)
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Dermatome: Skin
Myotome (Epimere): Deep back muscles - erector spinae and transversospinalis Myotome (Hypomere): Trunk and limb muscles Sclerotome: Vertebrae bones |
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***Quick dermatome innervation review...name anatomical landmark innervated by these spinal nerves:
C4, C6, C7, C8, T4, T6-T7, T10 |
C4 - Collar
C6 - Thumb C7 - Middle Finger C8 - Pinky T4 - Nipple Line T6-T7 - Xyphoid Process T10 - Umbilicus |
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Briefly summarize scleratome involvement in vertebrae formation
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1 - Scleratome migrates towards, and surrounds neural tube (spinal cord).
2 - Fissures form through groups of migrated scleratome cells, effectively deviding them into infra-/supra-scleratomal tissue...this is to allow the passage of spinal nerves out of the neural tube into the myotomes. 3 - A group of supra-scleratomal tissue merges with a group a infra-scleratomal tissue beneath it to form a vertebrae. |
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What happens to the top half of the scleratome (suprascleratomal tissue) used to make the top cervical vertebrae (C1)?
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It contributes to form the base of the occipital bone.
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What are the two meanings of the word "dermatome"
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Derived from:
1) Portion of somite developing into skin 2) Sensory area of skin innervated by a specific spinal level. |
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In what anatomical landmark(s) does the notorchord end up in the developing embryo, and what does it eventually form?
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It ends up smack dab in the middle of the vertebral bodies, and it helps to form the nucleus pulposus
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Besides the vertebrae, what other vertebrae-related anatomical structure does the slerotome help to form?
Hint: It works along with the nucleus pulposus. |
Annulus fibrosis
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Primary vs. Secondary curvature of the spine
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Primary: kyphotic curvature of the thoracic spine (and sacral spoine), forms during fetal development
Secondary: lordotic curvature of the lumbar spine (and cervical spine), forms after birth |
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What is an identifying anatomical structure of a thoracic vertebrae?
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the articulating facets (articulates with the ribs)
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Vertebral level where the trachea bifurcates
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T4-T5
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Vertebral level of the sternal angle
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T2
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The two unique and identifying foramen seen on cervical foramen contain what?
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vertebral arteries
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The most common cause of disability of persons < 45 years old
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Chronic Back Pain
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Common associations for back pain?
Hint: GRASPS...OW! |
GRASPS...OW!: Genetics, recreational activities, age, secondary gain (money seekers, i.e. jackpot jurisdiction), psychological status, smoking, occupation, weight.
Note: though these are all associated, it's not easy to assign causation to any one in particular. |
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***YELLOW flags for back pain
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PSYCHOLOGICAL factors shown to be indicative of long term chronicity and disability:
- depression/emotional distress - fear avoidance behaiors - expecting passive (rather than active) treatment leads to better outcomes - social problems - financial problems |
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***Define: radiculopathy
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- pain from spinal nerve root compression/irritation
*** - usually disc herniation in lumbar spine, or arthritis/degenerative-changes in cervical spine |
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Define: spondylolysis
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- defect in pars interarticularis
- can be congenital - can be due to excessive lumbar hyperextension - worse with activity/standing - better with rest |
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Define: spondylolisthesis
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- slippage of one vertebrae upon another vertebrae
- a progression of spondylolysis - can get stenosis and leg pain |
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Spine fractures are most commonly due to
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osteoporosis
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***RED flags associated with neck and back pain
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RED FLAGS = YOU MUST GET IMAGING
- fever and unexplained weight loss - bladder/bowel dysfunction, disturbed gait, saddle anesthesia - history of cancer - progressive neurological deficit - age of onset < 20 years or > 50 years - trauma - pain at rest - immunosuppression - drug use (I.V.) |
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***T of F: Chronic spine pain is common in Western societies
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True:
- 85% lifetime prevalance - 5% of all healthcare visits |
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***T or F: Chronic spine pain is a significant economic burden on society due to both health and indirect costs.
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True:
- #1 cause of disability in those < 45 years old |
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***What is the age range of those most-commonly effected by chronic spine pain
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45-64 years old
(remember, they were more commonly effected than the age 18-44 range? I thought that was a funny statistic...) |
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***T of F: It's relatively common to be able to pinpoint a cause of chronic - and it's usually wear and tear.
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False and False! Not only are there multiple risk factors to the development of back pain, recent studies argue against the traditional wear and tear theory. There are, however, definite association/correlations.
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***What is the most common diagnosis of spine pain?
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"Non-specific spine pain"
- There are still multiple other pain "generators" - Don't forget about the "red flags" |
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What is the "chronic pain problem"
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Chronic pain (pain lasting > 3 months) that causes 10-20% of the population grief and the country all sorts of economical and social burdens ($70 billion annually, 500,000 work days lost per year)
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Define these types of pain:
1) Nociceptive 2) Neuroligical 3) Psychogenic |
1) Nociceptive: Due to stimulation of nociceptors indicating actual tissue damage
2) Neurological: Damage to either central or peripheral nervous system causing the preception of pain 3) Psychogenic: Originating in the mind. |
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Which size of sensory neurons conduct pain? (Big or small, and what type?)
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Small ("A-delta", and "C" types)
Sizes from biggest to smallest: A-alpha, A-beta, A-delta, C |
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At which anatomical location do opioids exert their effect?
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dorsal horn of the spinal cord.
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Define: Anesthesia
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Anesthesia – lack of pain perception. Greek: an-
‘without’ + aisthesis ‘sensation' |
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Define: Dysesthesia
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Dysesthesia: An abnormal and unpleasant sensation, whether spontaneous or evoked. "I feel funny."
Greek: dys = 'difficult' + aisthesis = 'sensation' |
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Define: Analgesia
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Analgesia: without pain
Greek: an = 'not' + algein = 'feel pain' |
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Define: Hyperalgesia
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Hyperalgesia: Increased response to a stimuli that is normally painful.
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Define: Allodynia
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Allodynia: Increased response (to the point of the sensation of pain) to a stimuli that is normally non-painful. (e.g. sunburns make any sort of contact painful.)
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Define: Anesthesia Dolorsa
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Anesthesia Dolorsa: Pain in an area or region which is anesthetic. (Dr. Brogan in lecture said this is terrible - stuff that shouldn't be having sensation! e.g. "My hair hurts!")
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Describe gate control theory of pain
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Other impulses coming down from the brain can "turn off" other pain signals.
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Pharmacologic Management: Nociceptive Pain
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1.Tylenol
2.NSAIDS 3.Opioids 4.Membrane stabilizing agents - Gabapentin - Pregabalin 5.Topical agents - NSAIDs - Local anesthetics |
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Pharmacologic Management: Neuropathic pain
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1.Membrane stabilizing agents
- Gabapentin - Pregabalin - (Others) 2.Tricyclics, e.g. desipramine 3.Duloxetine (selective norepi and serotonin re-uptake inhibitor) 4.Topicals - Lidocaine - Ketamine - Capsaicin (Cool Beans!) 5.Opioids 6.Others: intrathecal clonidine, ketamine, ziconitide |
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Spinal Cord Stimulation: Indications
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• NEUROPATHIC pain that is refractory to conventional management
• Failed Back Surgery Syndrome • Chronic lumbosacral radiculopathy • Arachnoiditis • Pelvic and abdominal pain • Complex regional pain syndrome • Ischemic limb pain • Intractable angina • Post thoracotomy pain syndrome |
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Intrathecal Pump/Infusions: Indications
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• For pain refractory to numerous forms of treatment.
• Presence of unacceptable side effects with standard pain medications |
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LUMBAR radiculopathy: When you herniate a lumbar disc, it usually hurts the nerve root exiting _______ the segment. (at/above/below)
CERVICAL radiculopathy: When a cervical disc segment has a problem, it usually hurts the nerve root exiting _______ the segment. (at/above/below) |
LUMBAR: below (the lower number in the name of the segment, e.g. L4-L5 segment problem leads to a hurt L5 nerve)
CERVICAL: at (still the lower number...C4-C5 problem leads to a hut C5 nerve) |
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***Myotomes:
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L2/3 - hip flexion
L4 - knee extension, hip aduction L5 - ankle dorsiflexion, hip abduction S1 - angle plantar flextion, toe flexion |
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***Muscle stretch reflex:
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L4 - Patellar tendion
L5 - Medial Hamsgtring S1 - Achilles tendon |
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How helpful is imaging studies with regard to radiculopathies?
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It's a mixed blessing - sensitive but not specific. (High number of false positives.) You generally AVOID imaging unless a "RED flag" is present.
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Describe EMG studies in Radiculopathy
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It's a nerve conduction study that tests peripheral motor and sensory fibers.
- highly sensitive (normal person will never have abnormal test) - sensory test normal indicating intact DRG - motor tests normal indicating no significant axonal loss |
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Is reinnervation possible?
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Yes; it takes a long time, it changes the architecture of the motor unit, the amplitude of action potential increases due to increase of motor unit territory of surrounding axons.
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***Myotome testing:
C5, C6, C7, C8, T1 |
C5 - deltoid, ext. rotators
C6 - Wrist extensors and pronation C7 - Triceps C8 - Thumb abduction T1 - Finger flexion at DIP |
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***Muscle Stretch Reflex testing:
C5, C6, C7, C8 |
C5 - biceps
C6 - brachioradialis C7 - triceps C8 - finger flexors |
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Indications for surgical treatment of radiculopathy
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– Progressive weakness
– Failure to progress despite PT, NSAIDs, opioids, injections. – Inability to control pain to participate in medical therapy. |
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How does injection treatment for radiculopathy work, and does it work well?
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It can work very well; it decreases the inflammatory source.
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Drugs used to treat radiculopathy and their mechs. of action
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(most radiculopathies have some component of inflammation)
- NSAIDs: directly inhibit the inflammation - Corticosteroids: directly inhibit the inflammation - Opioids: bind to mu receptors in spinal cords (block pain) - tricyclic antidepressants: norepi reuptake inhibition, blocks descending pathways |
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The #1 reason for peopel aged >65 y/o to undergo spinal surgery
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Spinal stenosis
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Differentiate claudication due to vascular causes versus neurogenic
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Depends on what position the patient is in, any activity where the patient leans forward (flexion of spine) will actually relieve symptoms of the neurogenic patient. (It opens up the posterior aspect of the spinal canal.)
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The ligamentum flavum gets its name due to the abundance of this material.
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elastin
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The spinal cord usually terminates at this vertebral level and tapers down (conus medularis) into the cauda equina.
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L1
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Causes for spinal stenosis
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Hint: SSDs are TITS
spondyloarthropathy (degeneration of spine), spondylolisthesis, degenerative scoliosis, trauma, infection, tumor, short pedicles (congenital) |
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Typical clinical presentation for spinal stenosis
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- >40 y/o
- claudication (differentiate neurogenic vs. vascular cause--Sx relief with rest/flexion = neurogenic) - NORMAL physical exam findings |
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Surface anatomy locations to find these vertebral levels:
T3, T7, T10, L4, S2 |
T3 - Scapular Spine
T7 - Scapula (inferior angle) T10 - Umbilicus L4 - Iliac Crest S2 - Posterior-superior iliac spine (dimples immediatly superior to your butt) |
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Name the muscles of the erector spinae
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Hint: Salt Lake International
- Spinalis - Longissimus dorsi - Iliocostalis |
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Unilateral pars interarticularis problems lead to ________.
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spondylolysis
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Bilateral pars interarticularis problems lead to ________.
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spondylolithesis
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T or F: Most cases of spondylolisthesis and spondylolysis can be treated non-operatively
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true
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Indications for surgical treatment of spondylolisthesis or spondylolysis
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- high-grade spoldylolisthesis (i.e. a big slip of a vertebrae)
- Intractable pain after > 6 months non-operative Tx - significant neurological issues |
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What is the most common type of spondylolisthesis?
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"isthmic" followed by "degenerative"
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***Best method of detecting scoliosis
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Bending Test
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***General Types of scoliosis
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Adult:
- Adult idiopathic - started as child, and pt. is now an adult - Adult degenerative scoliosis - starts as an adult due to disc degeneration Pediatric: - Idiopathic - most common - Congenital - Neuromuscular - Curves from a disorder (e.g. neurofibromatosis) |
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***Most common type of scoliosis
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Adolescent Idiopathic Scoliosis
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***What gender is most affected.
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Female (almost 9:1 female:male ratio)
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***The type of scoliosis that can be lethal
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"Early Onset" of pediatric scoliosis:
- infantile (birth - 3 y/o) - Juvenile (3 - 9 y/o) |
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***Main indicators of scoliosis curve progressing:
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Scoliosis progresses most during growth:
- Age of onset - skeletal maturity of the patient - magnitude of the curve - curve pattern |
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***3 Treatment options for adolescent idiopathic scoliosis
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- observation
- non-operative treatment with bracing - surgical intervention |
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***4 factors which help determine treatment for adolescent idiopathic scoliosis
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- age and remaining growth potential
- curve pattern/magnitude (>45 degrees) - Curve progression rate (5-10 degrees in <6 months) - Cosmetic appearance |
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***When is scoliosis most likely to progress?
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During GROWTH . . . the more growing you have left to do, the worse the scoliosis is going to get. This is why early onset pediatric scoliosis can be lethal.
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Scoliosis can be seen in diseases/conditions such as...
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- Marfans Syndrome
- neurofibromatosis - Cerebral Palsy - Duchenne's muscular dystrophy |
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The mortality rate of spinal cord injury
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95%
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With spinal cord injuries, what are the common ways people are injuring their spinal cords?
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1 - motor vehicle accidents (48%)
2 - falls (28%) 3 - violence (15%) 4 - sports (8%) 5 - other (9%) |
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Term used for reducing nerve death after the injury, and some examples of how they do it.
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- "Neuroprotection"
- Antinflammatories, surgery, stop the leaking |
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Easiest and hardest level of difficulty in researching a cure for spinal cord injuries.
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Easiest: optomize spontaneous regeneration
Hardest: appropriate reconnectivity and long tract regrowth. |
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T or F: A cure for spinal cord injury is mainly being able to walk again.
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False - improvements in any other type of problem, such as sexual function, bladder/bowel control, mobility, pain, spasticity, etc, lead to huge improvements and has value.
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One of these biggest challanges treating patients with spinal cord injuries in rehab.
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Bed sores (50% prevalence)
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Briefly describe the ASIA classification system for spinal cord injures.
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describes the amount of function (sensory and motor) a patient with a spinal cord injury has by assigning a letter A (complete paralysis) through E (nearly normal functioning).
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T or F: Patients with spinal cord injuries are still fertile, and sexual activity is still possible.
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true
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Achondroplasia: Describe, Genes involved, labs, life span
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- Large skull, short limbs
- FGFR3 gene anomaly (85% spontaneous, adv. paternal age) - normal labs - normal life span. |
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Osteopetrosis: describe, mechanism, complcations
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- "marble bone"
- reduced osteoclast funct., lacking carbonic anhydrase - risk of fractures |
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Osteomalacia: describe, cause,
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- Rickets for adults. Decreased bone mineralization. (Rickets = decreased bone mineralization in GROWING bone.)
- usually due to Vit. D deficiency (either inadequate sun exposure, diet, absorption, etc...) |
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Osteomalacia: clinical findings, labs, management
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- bone pain, muscle weakness, fractures, waddling gait
- low Vit. D (measured 25-OH Vit. D), low Ca, low PO4, high PTH, high alk phos, low urine Ca - treat with Vit. D. (usually Ergocalciferol, sometimes cholecalciferol), and AVOID osteoporosis drugs like bisphosphonates (lower blood Ca) |
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Paget's Disease: Describe, Dx, Tx
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- focal areas accel. bone remodeling, disorganized, unknown etiology (mostly pelvis, skull, long bones)
- Dx with radionucleotide bone scan (Pagetic lesions = higher metabolism) - Tx with bisphosphonate |
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Bisphosphonates: purpose, MOA, pt. instructions,
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anti-resorption drug, attaches to bone @ hydroxyapatite locations, inhibits osteoclasts (slows, apoptosis), poor oral absorption - take on empty stomach
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Osteogenesis Imperfecta: Describe type I and II, physical exam findings, mutation, labs,
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mutation in genes for collagen (COL1A1, COL1A2), 8 types, bruising, frequent fractures, blue sclera, autosomal dominant, brown soft teeth.
- type I is most common and non-lethal, normal life expectancy - type II lethal |
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Osteoporosis: Definition
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compromised bone strength predisposing someone to an increased risk of fractures
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Osteoporosis: Disease burden
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responsible for 2 million fractures a year (and getting worse the more soda society is drinking)
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Osteoporosis: Pathophysiology
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osteoclast and osteoblast activity isn't lining up quite right, and we're breaking down more than building back up.
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Osteoporosis: Risk assessment, screening, and Dx
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Risk: low bone mineral density, personal hx of fracture, family hx of fractures, low body weight, smoking, adv. age, oral glucocorticoid use >3 months
Screening: Google "FRAX" Dx: all of the above, plus bone mineral density tests and labs |
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Osteoporosis: Treatment options
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- Ca/Vit. D
- Weight bearing exercise - Medications |
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Osteoporosis Drugs: HRT
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(Hormone replacement therapy)
- decreases bone resportion - increases bone density, prevents fractures - no longer first line therapy |
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Osteoporosis Drugs: SERM
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(Raloxifene)
- decreases bone resportion - increases bone density, prevents vertebral fractures (but other locations not proven) - breast cancer prevention - hot flashes (-) - thromboembolic disease risk |
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Osteoporosis Drugs: bisphosphonate
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- just don't overdo it and oversupress the poor osteoclases b/c they're still important. (too much osteoblast activity will lead to disorganized and unstable bone building -- osteopetrosis)
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Osteoporosis Drugs: Denosumab
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- Inhibits RANKL Ab (which is important for osteoclast formation, survival).
- risk of infection - used for severe osteoporosis |
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Osteoporosis Drugs: Teriparatide
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(Parathyroid Hormone - PTH)
- "Pro-formation" drug - Wonder drug - EXPENSIVE ($1000/month) - daily injectable - osteosarcoma (-) |
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T1W, describe
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CSF: Dark
Fat: Bright |
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T2W, describe
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CSF: Bright
Fat: Bright |
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STIR (CT)
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CSF: Bright
Fat: Dark |
