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77 Cards in this Set
- Front
- Back
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Cervical (neck) disease syndromes
Classifications |
pain syndromes - strains and sprains
radiculopathy MYELOPATHY Segmental instability/spondylolisthesis - degenerative, neoplasms, trauma pediatric - congenital, hereditary, metabolic |
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Lumbar (low back) disease syndromes
classifications |
pain syndromes - strains and sprains
radiculopathy NEUROGENIC CLAUDICATION segmental instability - abnormal motion, spondylolisthesis - degenerative, neoplasms, trauma ADULT/PEDIATRIC SCOLOIOSIS |
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neck and back pain syndromes
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cervical and lumbar strain
whiplash low back pain |
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cervical and lumbar strain
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acute onset (hx of trauma, MVA, heavy lifting)
may have leg/buttocks pain AXIAL>APPENDICULAR 90% resolve within 6-8 weeks if pain does resolve: beware of chronic pain behavior, narcotic/drug seeking, true anatomic pathology (kids, elderly) |
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main this for strain
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educational reassurance
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low back pain
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70-85% of pop experience at some time
causes at cellular level: matrix metalloproteinases, phospholipase A2, nitric oxide, TNFa causes at macro - discs, facet joints, neural structures, muscles, ligaments, fasia |
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neck and back pain syndromes
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address underlying issue (obesity, poor physical condition)
NSAIDS at lowest does for extended time mobilization/aerobic exercise (running not good) traction bracing limited bed rest and narcotics TENS |
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radiculopathy etiology
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irritation of nerve root (lower motor neuron) as it leaves the spinal canal with variable:
pain weakness, numbness diminished reflex In distribution (myotome or dermatome) of nerve root |
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cervical dermatomes affected
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C5,6,7,8, and T1
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Lumbar dermatomes affected
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L4,5, and S1
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radiculopathy 2 peaks of incidence
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30-50 y/o = typical disc herniation
60-80 y/o = degenerative foraminal stenosis L5 more arthritic conditions |
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younger cohort chance of spontaneous improvement
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80-90% in first 6-8 weeks
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etiology
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compressive (90%) - herniation or spur
chemical (10%) glutamate - leak in disc itself |
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BEST dx resources and best predict outcome of surgery
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History and Exam
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cervical radiculopathy
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insidious onset - no hx of injury
"shoulder pain" is neck pain EXTREMITY> AXIAL 80%:20% arm pain INCREASES with neck extension or rotation TOWARD painful extremity - SPURLING'S SIGN DECREASED arm pain with placing hand on head |
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cervical radiculopathy positive test
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SPURLING'S SIGN
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Exam for Radiculopathy
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radicular pain with neck ROM - toward side of pain: may provoke parenthesis in DERMATOME
tendon reflexes - may be decreased in MYOTOME muscle strength - may be decreased in MYOTOME sensation may be diminished in DERMATOME pain relieved by placing hand on head |
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C5
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reflex: bicep
muscle: deltoid>bicep dermatome: lateral arm |
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C6
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MOST COMMON
reflex: brachio-radialis muscle: bicep>wrist extensor dermatome: thumb and index |
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C7
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2nd MOST COMMON
reflex: tricep muscle: tricep, wrist flexors, EDC dermatome: middle finger |
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C8
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muscle: finger FDP>interossei
dermatome: ring and small fingers |
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T1
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muscle: interossei
dermatome: medial arm |
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Lumbar radiculopathy Hx
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insidious onset +/- history of injury
pt says "HIP PAIN" means buttocks pain or BACK pain until clarified (TRUE HIP PAIN RADIATES TO GROIN NOT BUTT OR BACK) EXTREMITY>MIDLINE 80%/20% leg pain INCREASES with cough/sneeze/Valsalva INCREASED leg pain with forward flexion (SLR test) (pillow underneath knee) |
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Lumbar radiculopathy Physical Exam
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sciatic notch tenderness (L4,5,T1) - +
tendon reflexes - decreased in MYOTOME motor exam - may have weakness in MYOTOME SLR test (femoral stretch test at L4 or above) - may provoke parenthesis in DERMATOME BRAGGARD'S SIGN (confirms SLR test) - opposite |
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L4
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Reflex: patella
Muscle: Quad Dermatome: knee and medial leg |
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L5
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reflex: none
muscle: EHL/TA dermatome: lateral leg and dorsum of foot |
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S1
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reflex: ankle
muscle: gastroc dermatome: calf, heel, and plantar foot |
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Testing: X-Ray
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RISK FACTORS: age >50 or <18, neuro deficit, bowel or bladder problems, IV drug use, steroid use, systemic symptoms (night pain, fever, chill, wt loss)
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EMG/NCS
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Electromyography/Nerve Conduction System "Nerve Study"
good for equivocal cases - DETERMINE INVOLVED SPINAL LEVEL (when dermatome and myotome don't match up) POOR SUB FOR HX and EXAM: false +/- |
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MRI
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VERY HIGH FALSE POSITIVE
only 30% nl subjects have nl MRI only good if thinking about Sx NOT a SCREENING TOOL |
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MRI advantage/disadvantage
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advantage: NONINVASIVE - good for visualizing neural compression from soft-tissue, infection, or ligamentous trauma AND NO RADIATION (better then CT scan)
disadvantage - metallic artifact and contraindicated with older pacemakers, cardiac valves, and eye/ear implants |
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MRI caveat
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high rate of abnormal findings in ASYMPTOMATIC PTS
ONLY ORDER if dx can't be made on Hx, PE, and X-rays DO NOT ORDER FOR SIMPLE NECK OR BACK PAIN USE FOR RADIATING ARM OR LEG PAIN |
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level to look at MRI for majority of pts with trauma, disc herniation, spinal stenosis, and infection
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T2
T2=H20 T2 sagittal then T2 axial |
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level to look at MRI for Tumors
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T1
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Treatment for Cervical/Lumbar Radiculopathy
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younger cohort 80-90% improve spontaneously
Need Additional info: bowel/bladder problems? progressive weakness? how long pain been present? how bad is it now? compared to 2 weeks ago? |
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Treatment options
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Time - 6-8 weeks and get better
NSAIDS Medrol dose pack (glucocorticosteroid) selective nerve root injection (steroid:Depo Medrol) Sx 10-20% need this |
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Selective nerve root injection
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day sx
local anesthesia indications: severe or plateau of pain at unacceptable level therapeutic, can be dx test also |
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Epidural steroids
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blind - transligamentous (ligamentum flavum)
fluoroscopically guided - transligamentous (inter laminar) or transforaminal (SNRB) selective nerve root block |
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Cervical Sx
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ACDF most common
indications: 6 weeks of pain with no improvement < 6 weeks with unbearable pain failure of epidural steroids myelopathy or bowel/bladder involvement progressive weakness - can't lift anything |
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ACDF procedure
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general anesthesia
1.5-2 hours bone graft - autograft or allograft (cadaver) plate fixation typical incision 1.5-2 in blood loss <100cc |
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ACDF results
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90-95% with arm pain resolve in PACU
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Lumbar Sx
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microdiscectomy AKA decompression or diskectomy or "laser discectomy"
indications: > 6 weeks of pain no improvement unbearable pain < 6 weeks failure of epidural steroid progressive weakness in legs |
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cauda equina synrome
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Surgical EMERGENCY
anesthesia in the groin bladder retention |
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Microdiscectomy
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remove herniated disk only under a microscope - only herniated portion
30-90 mins incision 1-1.5in blood loss <100cc |
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Microdiscectomy results
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90-95% leg pain resolved in PACU
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Cervical Myelopathy etiology
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narrowing of central canal of cervical or thoracic spine causing COMPRESSION OF SPINAL CORD (not nerve root only)results in upper motor neuron compression and spasticity
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thoracic involvement
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causes same lower extremity problems but NO UPPER EXTREMITY PROBLEMS
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lumbar equivalent
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LUMBAR SPINAL STENOSIS
results in nerve root compression NOT spinal cord compression |
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cervical myelopathy History
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subtle, not attributed to age
global hand numbness diminished dexterity (ties and buttons) dysgraphia gait disturbance neck pain associated radiculopathy |
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earliest finding
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LOSS OF TANDEM GAIT
sobriety test |
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tests for cervical myelopathy
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sobriety test
hoffmans reverse radial reflex hyperreflexia (late finding) clonus (late finding) |
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Hoffmans test
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middle finger flicked causing flexion of other fingers involuntarily
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clonus
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recurrent contraction/relaxation of involved muscles
more than 3-4 beats is pathologic "sustained" clonus is persistent |
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treatment for cervical myelopathy
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Surgery
decompress spinal cord by increasing size of cervical canal |
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methods
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ACDF
posterior laminectomy posterior laminoplasty |
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outcome
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walk better immediately
upper extremity take longer to resolve ALL PROBLEMS DONT RESOLVE COMPLETELY, DUE TO PERMANENT DAMAGE/INJURY TO SPINAL CORD |
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last complaint to improve
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numbness
can take 18 months |
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neurogenic claudication
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narrowing of central lumbar spinal canal causing decrease in venous flow from nerve roots, resulting in vague but severe pain in low back, butt, and thighs
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characteristics
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older pop >60 y/o
central lumbar stenosis - MULTILEVEL very similar hx to aorta-iliac insufficiency relentless progression severely curtail activities similar to vascular claudication (but below knees) |
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Hx
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symptoms INCREASE when standing/walking for >5-15 mins
sitting down/resting alleviates symptoms back, bilateral butt, and thigh pain with standing/walking (central canal narrower when standing) grocery cart sign sitting stool in front of shower or sink |
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Exam
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normal with signs of degenerative diseases
abnormal pulsations (distal) dermatome numbness myotome weakness standing tolerance - time pt before needs to sit walking tolerance - time pt before needs to rest |
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Testing
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X-ray (degenerative changes, disc space narrowing)
EMG/NCS (normal/stress) MRI (narrowing and compression) |
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if no impressive central stenosis suspect
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vascular claudication or insufficiency
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Treatment Neurogenic Claudication
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epidural steroids (short term)
Sx: Multi-level spinal decompression laminectomy (not always need fusion) - lamina and spinal processes taken off |
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Segmental Instability
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increase in motion b/w segments
>4.5mm in lumbar >3.5mm in cervical >11 degrees more motion than adjacent segments |
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Due to
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trauma
isthmic spondylolisthesis tumor or infection found with radiculopathy BUT major symptoms usually AXIAL PAIN IN NECK OR BACK |
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Treatment
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Sx with 2 components
1. decompression to treat radiculopathy 2. fusion to treat axial pain and stabilize underlying instability |
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outcomes
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80% success
results proportional to degree of stability achieved radiculopathy resolves FIRST and axial pain improves over time with fusion |
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Neoplasms
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incidence: metastatic tumors WAY MORE COMMON then primary tumors
skeleton - 3rd most common site of mets (lung and liver 1st) spinal common - MOST COMMON skeletal site |
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tumors that spread to spine
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BLT with Kosher Pickle
breast, prostate, lung, kidney, thyroid 70% found in thoracolumbar spine 20% lumbosacral 10% cervical |
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primary tumors
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only 10% WILL INVOLVE THE SPINE
many are asymptomatic and remain undx AGE and PRESENTATION important to differentiate benign vs malignant |
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benign spinal tumors
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less common than malignant primary tumors
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presentation of neoplasms
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85% have BACK PAIN as CC
onset of pain characterized as: slow gradual progressive PAIN AT NIGHT>PAIN DURING DAY unrelated to mechanical factors - PAIN EVEN AT REST |
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testing
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standing X-rays for >6 week back pain
obtain immediately for any cancer pt with new localized pain MRI Bone scan - early detection chest, abd, and pelvic CT lab tests |
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treatment
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ONLY 10% of all spinal mets will require sx
(90% of cancer deaths will have spinal mets at autopsy) |
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Goals of Tx
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control pain
restore or maintain neural function correct instability prevent pathologic features TREATMENT IS NOT CURATIVE AND DOESNT PROLONG SURVIVAL |
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factors governing treatment for metastatic disease neoplasms
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hx of tumor
extent of metastasis sensitivity of PRIMARY TUMOR to radiation and chemotherapy remaining life expectancy pt and family choices |
