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46 Cards in this Set

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Which part of the spine is most susceptible to injury
Thoracolumbar junction (50% of all vertebral fxes, 40% of all spinal cord injuries occur at T11-L2)
Posterior column
- Posterior bony arch
- Spinous process, facets, lamina, pedicle - posterior bony arch
- Interconnecting posterior ligamentous structures
- Supraspinous ligament, interspinous ligament, lligamentum flavum, facet joint capsule
Anterior column
- Anterior longitudinal ligament
- Anterior portion of annulus fibrosus
- Anterior vertebral body
Middle column
- Posterior vertebral body
- Posterior portion of annulus fibrosus
- Posterior longitudinal ligament
Stable back injuries
Intact posterior and middle column - prevent hyperflexion, extrusion of bone/disc into canal, prevents agains significant subluxation
Mechanical instability back injury
Two of three columns are injured, associated with pain but no neurological involvement
Primary determinant of mechanical stability in thoracolumbar spine
Middle column
Mechanical and neurological instability injury involves _
Damage to all 3 columns
Compression fracture of spine
- Fracture of the anterior portion
- Middle column is intact
- 2 mechanisms - anterior or lateral flexion
- Posterior column may be disrupted in tension as upper segments hinge forward on intact middle column
- Can be caused by significant axial loading ( jumping out of window and landing on feet), flexion injuries (anterior compression fractures)or sidebending injuries (lateral flexion injuries)
- Can involve superior or inferior end plates or both or buckling of anterior cortex
Burst fractures of spine
- Disruption of posterior wall of vertebral body (middle column) and anterior column
- Mechanism - axial loading
- Neurologic injury
- Can be accompanied by lamina and pedicles fractures
Flexion-distraction injuries of spine
Failure of posterior and middle columns in tension
- Anterior column serves as fulcrum and stays intact
- Mechanism - seat belt injury in MVA (w/out use of shoulder belt)
Fracture-Dislocation injury of spine
- Involves all 3 columns
- Differentiated from flexion distraction by disruption of anterior longitudinal ligament
- Result of compression, tension, rotation or shear forces
- Associated with highest incidence of neurologic defficits
- Very unstable, always need surgical treatment
Define scoliosis
Structural lateral curvature with rotation that occurs at or near puberty and for which no cause has been identified
How do you diagnose scoliosis
Suspect by presence of body asymmetry best seen on Adams forward bending test,confirm by presence of at least 10 degree curvature by Cobb method on standing PA radiograph of the spine
Cobb method of measuring degree of scoliosis
Find start of curve and use superior vertebra to make aline, find end of curve and use inferior surface to make a line - take angle
Describe prevalence of scoliosis
Overall female predominance of 3.6 :1, for small curves in the range of 10 degrees prevalence is equal, in curves of larger magnitude overwhelming female predominance
If you have left thoracic convexity what does it tell you
RED FLAG - spinous anomaly like tumor - get MRI
Common convexities in scoliosis
Right thoracic and left lumbar
How are curves in scoliosis described
By the area of spine in which apex is located
Which curve is more prone to progression
Double curve
5 signs of increased ligamentous laxity
- Thumb MCP joint hyperextension
- Finger MP joint extension
- Elbow hyperextension
- Knee hyperextension
- Increased dorsiflexion of ankle
Which cardiac abnormality is common in patients with scoliosis
Mitral valve prolapse
Why do you do skin exam in patients with scoliosis
Look for cafe-au-lait spots, hemangiomas, neurofibromas, dimples, abnormal hair patches - suggest congenital intraspinal pathologies
Risser sign
Defined by amount of calcification present in iliac apophysis
1- 25 % ossification
2- 50% ossification
3- 75% ossification
4- 100% ossification
5- iliac apophysis has fused with iliac crest after 100% of ossification
What is considered to be progression of scoliosis
5 degrees and 10 for small curves
Risk factors for low back pain
Smoking
Obesity
Occupational hazards
Sudden pain onset with pain radiating below knee - possible dx?
Disk herniation
Difference between radicular and sciatic pain
Radicular pain goes below knee and sciatic pain doesnt go below knee
Special tests for SI joint
Pelvic rock test
Faber test
Direct palpation - best test
Waddells signs (supratentorial)
STORD
Simulation
Tenderness
Over-reaction
Regional disturbances
Distraction
Differential diagnosis of non-radiating low back pain
- OA (spondylosis)
- Back sprain/strain
- Cancer (mets or primary)
- Infection
- Fracture (compression or traumatic)
Differential diagnosis for radiating low back pain
- Lumbosacral radiculopathy
- Spinal stenosis
- Facet disease
- SI dysfunction
- Myofascial pain
Cauda equina syndrome
- Saddle anesthesia (groin and upper inner thighs numbness)
- Diminished neurological responses (decreased reflex)
- Bladder retention
- Lax anal sphincter
- Foot drop or other major muscle weakness in legs, ankles or feet
- SURGICAL EMERGENCY!!!!!!!!
Low back pain + cancer
- Fever/chills
- Unexplained weight loss
- Persistent NIGHT PAIN
- > 50 y.o
- Previous history of cancer
Low back pain + spinal infection
- Fever with or w/out chills
- Worsening back pain especially at night
- Increased risk with IV drug users, immunocompromised, recent bacterial infections
Low back pain + possible epidural abscess
- MRI
- Fever
- Progressive neurological problems
- Localized tenderness over abscessed bone
Low back pain + AAA
- Sudden searing intensifying pain from back to legs
- Abdominal ultrasound
- Vascular consult
Sciatica usually involves what levesl
L4-L5, L5-S1
Dermatomal distribution of pain and numbness and tingling
L3/L4
L5
S1
L3/4 - anterior thigh pain
L5 - top of foot and great toe
S1 - pain in posterior calf, sole and/or lateral foot
Pseudoclaudication
- Over 50 years old (usually 60-70)
- Low back pain and leg pain with walking
- Unilateral or bilateral
- Increased pain with downhill walking and better with walking uphill
- Pos shopping cart sign
L2
Pain -
Sensory impairment-
Muscle weakness-
Reflexes decreased -
Pain - ANTEROLATERAL ASPECT OF THIGH

Sensory impairment-LATERAL ASPECT OF THIGH

Muscle weakness- HIP FLEXORS

Reflexes decreased - ADDUCTOR
L3
Pain -
Sensory impairment-
Muscle weakness-
Reflexes decreased -
Pain - ANTEROMEDIAL ASPECT OF THIGH

Sensory impairment-MEDIAL ASPECT OF KNEE

Muscle weakness- THIGH ADDUCTORS

Reflexes decreased - ADDUCTOR/PATELLAR
L5
L4
Pain -
Sensory impairment-
Muscle weakness-
Reflexes decreased -
L4
Pain - POSTERIOR ASPECT OF THIGH, LATERAL ASPECT OF LEG
Sensory impairment-LATERAL ASPECT OF LEG, BIG TOE
Muscle weakness- EXTENSOR HALLUCIS LONGUS, TIBIALIS ANTERIOR
Reflexes decreased -TIBIALIS POSTERIOR
L4
Pain -
Sensory impairment-
Muscle weakness-
Reflexes decreased -
Pain - ANTERIOR THIGH
Sensory impairment-PRETIBIAL REGION
Muscle weakness- QUADRICEPS
Reflexes decreased - PATELLAR
S1
L4
Pain -
Sensory impairment-
Muscle weakness-
Reflexes decreased -
L4
Pain - POSTERIOR ASPECT OF THIGH AND LEG
Sensory impairment-OUTER BORDER OF FOOT, SOLE, HEEL
Muscle weakness- TRICEPS SURAE (GASTROCNEMIUS + SOLEUS), GLUTEUS MAXIMUS
Reflexes decreased -ANKLE, MIDPLANTAR
What does straight leg raising test tell you
Radicular pain results from stretching nerve root compressed by herniation