Msk2: Spine Disorders And Spinal Cord Injury

Front 1

Prevalence of low back pain

Back 1

(28%) more common than HTN, CAD, stroke, sinus infections.

Low back pain is also most common among joints

It is most common physical condition for doctor visits

Front 2

What is Pain

Back 2

Unpleasant sensory AND emotional experience associated with actual or potential tissue damage or described in terms of such damage

Acute <3months, Chronic over

NOT just nocioception or the physical sensation

Front 3

Spinal Pain causes

Back 3

Trauma: Acute or Chronic, repetitive
Degeneration: normal aging and wear and tear
Instability
Malalignment
Inflammatory Disorders
Congenital anomalies
Infection
Tumor
Metabolic
Referal

Front 4

Natural History of Back Pain and Risk Factors

Back 4

50% improve in 1 week, 90% improve in 6-12wks

Though it improves, it often becomes recurrent and occasionally transitions to chronic

Risk Factors: Age, Gender equal to 60 then more likely female, cigarette smoking, obesity, weakness, weak core, depression, anxiety, alcoholism, occupation (heavy lifting ESP ROTATIONAL, vibration)

Front 5

F-MRI and emotional pain

Back 5

F-MRI allows localization on scans to "see" sensation of pain.

There is actually a neuroplasty change in the brain that make people more susceptible to pain

Front 6

Soft tissue disorders that can lead to pain

Back 6

Ligaments/Joints
Discs
Muscles
Nerves

Front 7

Spinal cord structure

Back 7

Body of vertebra in front, facet joints posteriorly, transverse processes, spinous processes, vertebral foramen (spinal cord location), and intervertebral foramina behind discs

Front 8

Muscle Injury; Acute muscle strain, myofascial pain syndrome

Back 8

Acute muscle strain - mild to moderate injury and most common cause of acute neck or back pain

Myofascial Pain syndrome (Fibrositis) - common cervical region pain due to tight bands or "nodules" in muscles that can refer pain and mimic carpal tunnel or radiculopathy

Front 9

Ligament Injury; Lumbar Sprain, Cervical Sprain/Strain

Back 9

Lumbar Sprain - Stretch or Tear of iliolumbar ligament (facet joint or sacroiliac joint) often with a muscle strain due to improper mechanics or overload. Accelerates degenerative wear and tear process in aging

Cervical Sprain/Strain - Trauma from falls, sports, MVC from behind "whiplash" leads to chronic pain in 25%

Front 10

Intervertebral Discs Role, Damage, and structure

Herniation location most common

Back 10

Structure: Annulus of dense fibrous tissue and fibrocartilage attached to endplates. Structured nucleus in middle. water loss from nucleus causes shortening during day. The lamellae of annulus are oriented perpendicular to each other to give strength and rotational resistance.

Role: allow movement (like a joint) between bodies, absorb shock, give 25% height of spine

Damage: Degenerative over time b/c avascular and don't really repair

Herniation: Annulus is thinnest posteriorly (posterior longitudinal ligament) and herniates here.

Front 11

Discitis

Back 11

An infection of an intervertebral disc. Difficult to treat because of poor penetration of antibiotics (mostly avascular)

Front 12

Degenerative Disc Disease Normal, Factors

Back 12

Normal loss of % equal to age (ie 20% by 20, 30% by 30...), due to water loss in nucleus, microteras of annulus, and structural changes

Factors: HIGH load, OBESITY, SEDENTARY, POOR FITNESS, SMOKING, age, apoptosis, collagen issues, ...

Front 13

Schmorl's Nodes

Back 13

Intervertebral disc herniation through vertebral endplate. Often asymptomatic and only seen on x-ray. Can be painful if acute though

Front 14

Spondylosis

Back 14

Degenerative arthritis of spine facet joint often PRECEDED by disk degeneration or trauma

Happens with age too, bone stress causes osteophytes and can impinge on nerves causing radiculopathy/sciatica/myelopathy (cervical region)

Front 15

Degenerative Spine Cascade

Back 15

Facet joint hypomobiltiy and degeneration with disc tears lead to dysfunction and herniation. Subluxation and disc resorption lead to lateral nerve entrapment

Enlargement of articular processes and osteophytes lead to one level stenosis then multilevel spondylosis and stenosis

Front 16

Acute Intervertebral Disc Injury Mechanism, and highest risk

Back 16

Flexion causes posterior annulus to stretch and nucleus displaced posteriorly if rotating and lifting away from body this is magnified

Fluid leaks, nerve inflammed = severe pain worse with flexion and sitting RELIEVED By lying and STANDING

Can have muscle spasms, postural deviation, ROM loss and pain radiating to arm or leg

Front 17

Spinal nerve radiculopathy and spinal cord myelopathy

Back 17

Radiculopathy - spinal nerves exit through canals above cervical or below (TLS) vertebra for which named. EXCEPT C8.

Spinal cord myelopathy - Can be affected by disc herniation cervical thoracid or L1 (b/c cord ends at L1)

Myelopathy is upper motor neuron syndrome so high tone, tight muscles, reflexes brisk.

Front 18

What do lumbar disc herniations compress, Radiculopathy associated

Back 18

cauda equina NOT nerves (end at L1)

95% occur at L5 to S1 and affect S1 more, the rest at L4 to L5 affecting L5 more

Leads to lower extremity motor, sensory, bowl, bladder and sexual dysfunction in the cauda equina syndrome

Front 19

4 other causes of low back pain by location

Back 19

Sacroiliac joint sprain - sacroiliitis (ankylosin spondylitis, Reiters)

Buttock and hip girdle myofascial pain - Piriformis syndrome (sciatic nerve entrapment), Gluteus medius or greater trochanteric bursitis

Internal Organ referral (uterus)

Vascular disorders - claudication pain with walking

Front 20

Neurogenic claudication

Back 20

Spinal stenosis leads to pain with walking, better in FLEXION. which is opposite of a disc herniation

Front 21

3 Column Concept in weight bearing, stability and instability

Back 21

3 columns are anterior column (first half of body), middle column (last half) and posterior column (spine and processes)

Stability - integrity of at least 2 columns

Instability - compromise of 2, often needs surgery

Front 22

Traumatic spinal fractures presentation, neurologic injury, treatment

Back 22

Presentation: young person, or MVC, falls, sports. Anything causing sharp compression of spine, Affect any vertebrae

Neurologic injury - radiculopathy or myelopathy. RARELY has this, usually just bone

Treatment: surgery if likely to decline over time

Front 23

Osteoporotic Insufficiency Fractures, Risk Factors, Vertebrae affected, Signs, Treatment (conservative vs surgical)

Back 23

Vertebrae: thoracic and lumbar most common

Risk Factors: Osteoporosis, elderly, women, poor calcium and VitD, tumors

Often multiple

Signs: kyphosis - forward curve. Loss of height and height. Progressive kyphotic deformity due to increased stress on extensors and loss of ability to stand upright

Can lead to pain, loss of independence...

Treatment: NEUROLOGIC EXAM, STABILIZE SPINE until know safe to move, surgery if cord is compressed or spine unstable.

Conservative: meds, brace, rehab, walker, time

surgery: decompression, fusion

Front 24

Spondylolysis Cause, Most common, Treatment. Spondylolisthesis

Back 24

Cause: pars interarticularis defect (congenital or traumatic fractures of extension or hyperextension or stress fracture. Fractures are worse extending/sitting than flexion/standing); L5 most common, often painless

Tx: 3-6 months without activity

Spondylolisthesis - slippage of L4 forward of L5 due to thiss, can compress nerve roots

Tx: if stable or asymptomatic may be conservative, if there is grade 3 (50-75% slippage) or higher do surgery (fusion)

Front 25

Scoliosis Cause, Risk Factors, Tx

Back 25

spine out of alignment

Cause: idiopathic mostly but can be due to congenital hemivertebra, neuromuscular disease (muscular dystrophy, CP, MS, SCI), fractures, degenerative spine disease

Adolescent, female moreso, rarely progresses

Tx: bracing for idopathic less than 40 degrees to prevent progression until child grown (23/24 hrs)

Surgery for over 50 degrees to prevent progression that could lead to pulmonary compromise, neurologic symptoms

Front 26

Initial treatment of acute spine pain

Rehab Phase 1

Rehab Phase 2

Rehab Phase 3

Meds

Back 26

Rest but be as active as can tolerate while avoiding heavy stress on back, OTC analgesics, Ice or heat

Rehab Phase 1 - education, pain control, posture, stretching, modalities

Rehab Phase 2 - local muscle endurance, strength. Focus on core

Rehab Phase 3 - self management with stretching, core stabilization, TENS, water or ice, weight and lifestyle management

Meds - NSAIDs for inflammation (not in PUD, renal, CV disese use steroids)

Opiods short term pain

Benzodiazepines, cyclobenszaprine for muscle relaxants

Front 27

Slouching does what?

Back 27

Cervical hyperextension, scapular mm stretching, excessive thoracic kyphosis, escessive lumbar lordosis and belly protuberance

Front 28

Lumbar "Core" muscles and exercises

Back 28

Abdominals, erector spinae, Lat dorsi (main movers)

Segmental stabilizers - first to atrophy

Neutral spine stabilizers for pelvis position

Exercises: Supine pelvic brace, dead bug, bridging, quadruped pelvic bracing

Front 29

Chronic Low Back Pain syndrome and contributors

Back 29

NOT a pathologic diagnosis but one of IMPAIRED FUNCTION, due to physical and psychological sequelae of chronic pain altering quality of life

Contributors: Increased Pain, Anxiety, Sleeping Problems, Not coping

Front 30

Chronic Pain Treatment

Back 30

Holistic approach, multidisciplinary for meds (just 1 manager), education, psychological tests, rehab, exercise, injections, meditation, therapy.... to promote overall health and wellness

Front 31

Low Back Pain burden of care, lifetime return to work rates

Back 31

More than 50% lost work days are due to musculoskeletal problems, pt loses independence, well being, etc. and caregivers lose time, work and emotional toll

If a worker on disability for 6 months only 50% return to work. 1 year only 25%, 2 years almost 0%.

Front 32

Summary of Spine pain

Back 32

often no specific diagnosis, common, frequently recurrent, occasionally chronic and expensive for resources, many treatments especially exercise

Front 33

Spinal Cord Anatomy, Role, Span

Vertebrae #, Spinal nerve number

Back 33

Part of CNS, bundle of spinal nerve fibers carrying messages back and forth from brain to body. Sensation to brain, other nerves to muscles, others to specialized fxns.

Extends from base of medulla oblongota through foramen magnum to L1 or L2 then ends in cauda equina. Travels through vertebral canal which protects it and provides support

33 vertebrae (7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused) and 4 coccyx (fused))

31 spinal nerves (8 cervical exit above vertebrae except C8, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal). C8 nerve down passes below vertebrae

Front 34

Long Tracts of the Spinal Cord: Ascending pathway and Descending pathway

Back 34

Bundles of axons in white columns relaying information

Descending pathway: carries motor commands, name starts with brain part and ends with spinal part (ex lateral corticospinal tract)

Ascending pathway carries info to the brain and named from spinal to brain.

Front 35

Spinal tract for
a)pain, temperature, crude touch
b)proprioception, vibration, fine touch
c) unconscious proprioception, joints in space, coordination

Back 35

a) Spinothalamic tract
b) Dorsal columns
c) Spinaocerebellar tract

Front 36

Upper motor neuron syndrome

Back 36

Brain or spinal cord injured leading to high tone, tight muscles resisting stretch, reflex increased. Can be seen in a neuro exam

Front 37

Tetraplegia Overview

Back 37

Impairment or loss of motor and sensory function in CERVICAL spinal cord that impairs function in arms, trunk, legs and pelvis

Can be done from vertebral damaged, crushing injuries, etc.

Front 38

Paraplegia Overview

Back 38

Impairment or loss of motor and/or sensory function in thoracic, lumbar or sacral segments of cord or cauda equina

Damage to conus medullaris at T12/L1 to cord and roots or cauda equina syndrome to roots

Front 39

ASIA scoring system overview, why is it performed

Back 39

Scores by level or completeness of damage

Performed to find level of injury and completeness for patients treatment and prognosticate

Front 40

Common dermatome levels and role (7)

Back 40

C2 back of head (NO C1 dermatome), C4 shoulder cap, T2 axilla, T4 nipple, T6 xiphoid, T10 umbilicus, L1 inguinal crease

Can test for nerve damage if loss of sensation at one of these

Front 41

Myotomes and role, Biceps, ECR longus, Triceps

Back 41

collection of muscle fibers innervated by motor axons in each root

Biceps C5 & 6, ECR longus C6 & 7, Triceps C7 & 8

Helps categorize injury

Front 42

Traumatic Spinal Cord Injury etiology, complications

Back 42

not as common as traumatic brain only 12k/year, with males more and around 16-30.

CAR CRASH > fall > violence > Sports

Complications: used to be renal failure or infection now its same as everyone respiratory and heart disease

Front 43

Central Cord Syndrome Overview, Presentation, Symptoms, Recovery

Back 43

An incomplete spinal cord syndrome due to arthritic changes in spine, calcificatoin of ligamentum flavum, neck hyperextension

Central part damaged, ventral osteophytes lead to impingment

Symptoms: upper limb loss, bladder dysfunction (returns), variable sensory loss

Presentation: elderly, hyperextension injuries, over half will walk again

Front 44

Anterior Cord Syndrome Overview, Presentation, Symptoms, Recovery

Back 44

An incomplete spinal cord syndrome

Lesion on anterior 2/3 of cord

Symptoms: preservation of light touch, propioception and deep pressure sensation. Absence of pain and motor function. BILATERAL

Recovery: Rare, only 15% get motor function back

Front 45

Brown Sequard Syndrome Overview, Presentation, Symptoms, Recovery

Back 45

An incomplete spinal cord syndrome

Ipsilateral Damage

Symptoms: Weakness and loss only on one side. Proprioceptoin loss on one , side, contralateral loss of pain and temp

Presentation: stab wound on one side of neck, MVA, GSW

Recovery: excellent, 75% walk again

Front 46

Conus Medullaris Syndrome Overview, Presentation, Symptoms

Back 46

Presentation: fracture around T12 - L1.

Symptoms: symmetric loss of pain, saddle abnormality of sensory loss, legs may be normal and has upper and lower motor neuron signs.

vulnerable to sudden flexion injury

Front 47

Cauda Equina Syndrome Overview, Presentation, Symptoms

Back 47

Presentation: multiple radiculopathies

Symptoms: lower motor neruon loss decreased reflexes and flaccid legs, sensory loss, often sacral sparing, neurogenic pain

Front 48

Autonomic Dysreflexia Overview, Treatment

Back 48

Spinal injury to T6 and above

Leads to imbalance SNS discharge. ELEVATED BP, Headache, sweating

This can be caused by any stimuli BELOW injury (kidney stone, ingrown toenail, fracture)

Treatment: elevate head, remove stimuli, Vasodilators (Nitroglycerin, nifedipine)

Front 49

Complications of Spinal Cord Injury

Back 49

deep vein thrombosis, neurogenic bladder, sexual dysfunction, neurogenic bowl, respiratory failure/pneumonia, spasticity, pressure ulcers

Front 50

Prognostication for Spinal Cord Injury, Patient main concerns, Poor prognostic factors, ASIA A ambulation potential

Back 50

Maximum recovery period is first 3-6 months, not much after 2 years.

Patient main concerns: walking, then bladder, then bowl, then sex

Poor prognosis: obese, old, poor motivation, more spasticity

ASIA A 80-90% remain complete, of that small percent 3-6% can get to functional walking

Front 51

Functional Goals & Loss & Mobility C1-C3 damage, C3-4, C5, C8-T1, T7-12, L1 - L5

Back 51

C1-C3; limited neck movement, need ventilator, need technology for speech. Mobility by wheelchair with head control

C3-4: head and neck control, may be able to shrug, initially need ventilator, Depend on caregivers. Same as C1 mobility

C5: head, neck control, shoulder shrug and control. Need caregiver. wheelchair with hand control

C8-T1: strength and precision of fingers (natural fxn), can live independently but need manual wheelchair. Can transfer

T7-T12 - better motor function and abdominal control, independent, manual wheelchair

L1-5 - decreased motor movement in hips and knees, walking viable with braces

Front 52

Impairment Definition!!!

Back 52

Loss of a body part or normal function of a body part due to amputation, spinal cord injury to legs, stroke, loss of normal range of motion in joints, weakness of muscles or vision loss

Front 53

Disability Definition!!!

Back 53

Restriction or inability to perform an activity in a manner considered normal for a person, often due to an impairment.

Specific to example (ex. visual disturbance is disability for truck driver but may not be for concert pianist)

Front 54

Handicap Definition!!!

Back 54

Impairment or disability prevents a person from fulfilling societal roles normal for that person depending on age, gender, social or cultural factors