Disorders of the Back and Spine, Ankylosing spondylitis, Cauda equina syndrome, Herniated nucleus pulposus, Kyphosis, Scoliosis, Spinal stenosis, Back strain, TOS, Torticollis, Trauma (Smarty PANCE)

How can a C-spine be evaluated?

1. Clinically by physical exam 2. Radiographically

Recommendation of orthopedic eval/or bracing if scoliosis is greater than __________________?

> 20° refer to orthopedics may need bracing

Spinal cord injury may be complete or incomplete what is the difference?

A complete spinal cord injury occurs when a person loses all sensory and motor function below the level of the spinal cord injury. When a person with a spinal cord injury retains some function below the level of the injury, they have an incomplete spinal cord injury.

In a patient over 65 with back pain, a history of tobacco use, atherosclerotic vascular disease, and an abdominal pulsating mass what should be of concern?

Abdominal Aortic Aneurysm (AAA)

What is the pathophysiology of thoracic outlet syndrome?

Abnormal dynamics between the anterior scalene, middle scalene, and the first rib causing compression

Complications of cauda equina syndrome?

Although cauda equina syndrome is not a fatal condition, it can cause severe neurological damage. If the condition is not treated quickly enough, this damage may be irreversible

Bamboo spine, HLA-B27 positive, ↑ ESR, Uveitis

Ankylosing spondylitis

Is ankylosing spondylitis is more common in (men/women)?

Ankylosing spondylitis is 3x more common in men with a peak onset at 15-35 years of age

Ankylosing spondylitis is an autoimmune disorder and almost all patients are positive for what?

Ankylosing spondylitis is an autoimmune disorder; almost all patients (90%) are positive for the HLA-B27 antigen.

Along with the spine, ankylosing spondylitis is characterized by the fusion of what joints?

Ankylosing spondylitis is characterized by the symmetric fusion of the spine and sacroiliac joints seen on imaging.

Ankylosing spondylitis is commonly associated with what GI disorder?

Ankylosing spondylitis is commonly associated with inflammatory bowel disease

Ankylosing spondylitis is characterized by what condition of the heart?

Ankylosing spondylitis is often accompanied by aortic regurgitation

Ankylosing spondylitis is characterized by what condition of the eye?

Ankylosing spondylitis is often accompanied by uveitis

What is anterior cord syndrome?

Anterior cord syndrome results from direct injury to the anterior spinal cord or to the anterior spinal artery. Patients lose motor and pain sensation bilaterally below the lesion. Posterior cord function (vibration, proprioception) is intact.

Describe the Adam's test

At routine screening, a patient is asked to flex forward and the scapula height is observed (known as Adam's test) if scoliosis is present, asymmetry in scapular height is noted

What is a back strain?

Back strain (sprain of the ligaments of the cervical spine) is a common injury routinely seen in the emergency department (ED). A back strain is chiefly the result of a stretch injury to the muscular and ligamentous elements of the cervical, thoracic, or lumbar spine.

Recommendation of bracing and/or surgery if scoliosis is greater than _____________?

Bracing or surgery if > 40°

Breathing may be impaired if the injury is at or above what level?

Breathing may be impaired if the injury is at or above the C5 segment.

What is Brown-Séquard syndrome?

Brown-Séquard syndrome results from unilateral hemisection of the cord. Patients have ipsilateral spastic paralysis and loss of position sense below the lesion, and contralateral loss of pain and temperature sensation.

Weakness of the deltoid, supraspinatus and infraspinatus

C5

Loss of sensation at the radial aspect of the forearm, thumb and index finger

C6

Loss of sensation in the middle finger

C7

Weakness of Finger flexors

C8

A patient presents with bilateral sciatica (pain and altered sensation in the legs), bladder dysfunction such as having to strain or an altered flow or altered awareness of the need to urinate, tingling or numbness in the saddle area between the legs and around the anus, and alteration of sexual sensation. What's the dx?

Cauda equina syndrome

Bladder/bowel dysfunction, saddle anesthesia, back pain with radiation to leg

Cauda equina syndrome

What is cauda equina syndrome?

Cauda equina syndrome is a rare but serious condition that describes extreme pressure and swelling of the nerves at the end of the spinal cord.

Treatment of cauda equina syndrome?

Cauda equina syndrome is best treated with decompression by a lumbar laminectomy, but a lumbar microdiscectomy may be used given a patient's unique situation. The patient will likely be kept in the hospital for a few days following the surgery to monitor recovery of motor and sensory function.

When caring for a patient with a spinal cord injury, management of which complication is the priority?

Decreased pulse oximetry reading

What are the most common causes of spinal trauma?

During a typical year, there are about 12,000 spinal cord injuries in the US or 40 cases per million persons per year. The most common causes of spinal cord injuries are motor vehicle crashes (48%) and falls (16%). The remainder of spinal cord injuries are attributed to assault (12%), sports (10%), and work-related injuries. In older patients, falls are the most common cause. About 80% of patients are male.

What are the first signs of cauda equina?

Early symptoms of cauda equina syndrome can include: Lower limb weakness and intermittent changes in sensation, such as numbness. "Saddle anesthesia" - loss or diminished sensation in areas where a person would sit on a saddle Urinary and/or bowel problems, such as retention or incontinence.

What is the diagnostic test of choice for TOS?

Electrodiagnostic testing is warranted in all patients with suggestive symptoms of TOS, and MRI of the brachial plexus, cervical spine, or both is usually also necessary.

Name a tumor necrosis factor decoy receptor used in the treatment of ankylosing spondylitis.

Etanercept, a tumor necrosis factor decoy receptor, is a medication used in the treatment of ankylosing spondylitis.

What is the Adson maneuver?

Evaluates for arterial compromise - the patient: 1. Extends neck (lifts head) 2. Takes a deep breath and holds 3. Turns head toward examined side The practitioner: Monitors radial pulse on examined side ● Test finding is positive if the radial pulse decreases or disappears during maneuver

Define kyphosis?

Excessive outward curvature of the spine, causing hunching of the back. Various factors can lead to excessive kyphosis

What are the symptoms of a back strain?

Generally presents with pain and/or stiffness with movement, difficulty bending, and no radicular symptoms

Radiculopathy (pain below the knees), (+) straight leg raise

Herniated nucleus pulposus

Diagnosis of cauda equina syndrome?

If symptoms suggest cauda equina syndrome, MRI should be done immediately if available. If MRI is unavailable, CT myelography should be done.

What is the treatment of back strain/sprain?

In the absence of 'red-flag' symptoms, treat conservatively with NSAIDs, heat or ice, PT, and home-based exercises (avoid bed rest) ● May include a muscle relaxant such as cyclobenzaprine or short-term use of a benzodiazepine

Name two anti-tumor necrosis factor monoclonal antibodies used in the treatment of ankylosing spondylitis

Infliximab and adalimumab, anti-tumor necrosis factor monclonal antibodies, are medications used in the treatment of ankylosing spondylitis.

What typically causes spinal stenosis?

It is generally caused by degenerative arthritis (spondylosis) of the spine in older adults with associated osteophyte formation and disk bulging that encroaches on the central canal and the neural foramina

Hunched forward (humpback)

Kyphosis

Kyphosis is defined as a curvature of the spine > than ____________ degrees on x-ray?

Kyphosis is defined as a curvature of the spine measuring 50 degrees or greater on an X-ray

ANTERIOR thigh pain, sensory loss medial ankle

L4

Anterior thigh pain

L4

Loss of knee jerk, weak knee extension - quads

L4

Weak ankle dorsiflexion and loss of knee jerk

L4

Weakness of ankle dorsiflexion

L4

Lateral thigh/leg, hip and groin paresthesias and pain with loss of sensation at the dorsum of the foot

L5

Sensory loss to LATERAL thigh/leg hip and groin paresthesia and pain, DORSUM (TOP) OF THE FOOT, especially between 1st and 2nd toes

L5

Usually no diminished reflexes

L5

Walking on heels more difficult than walking on toes

L5

Weakness of BIG TOE EXTENSION, walking on heels more difficult than toes

L5

Motor nerve root for great toe?

L5 (remember L5 is the "largest" so it affects the largest toe)

Hunched backward (sway back)

Lordosis

What is the Dx? Back pain after lifting heavy boxes with lower extremity weakness decreased sensation and + straight leg raise

Lumbar herniated nucleus pulposus (HNP)

What is lumbar spinal stenosis?

Lumbar spinal stenosis (LSS) is the narrowing of the central or lateral lumbar spinal canal caused by degenerative joint disease, which puts pressure on the cord or sciatic nerve roots before their exit from the foramina.

What is the treatment for thoracic outlet syndrome?

Most patients who have a thoracic outlet compression syndrome without objective neurologic deficits respond to physical therapy, nonsteroidal anti-inflammatory drugs, and low-dose tricyclic antidepressants. Consider surgery if patients have a cervical rib or subclavian artery compression and neurovascular deficits that progress despite conservative treatments.

What is neurogenic claudication?

Neurogenic claudication is the most common symptom associated with spinal stenosis and is described as positional back pain and referred pain occurring in the buttocks, thighs, or calves during walking, running, climbing stairs, or even standing. This is a symptom of nerve root compression. Neurogenic claudication results from central canal stenosis, whereas radiculopathy is the sequelae to lateral recess encroachment.

What patients can have their C-spines cleared by a physical exam?

No neck pain on palpation with full range of motion (FROM) with no neurologic injury (GCS 15), no EtOH/drugs, no distracting injury, no pain meds

Describe the classic presentation of lumbar spinal stenosis

Pain in the elderly that increases with extension (walking downhill and standing upright) and is relieved with flexion at the hips and by leaning forward (sitting, leaning over a shopping cart)

Patients with ankylosing spondylitis often present with what chief complaint?

Patients with ankylosing spondylitis often present with a chief complaint of chronic low back pain + morning stiffness with radiation to the thighs and decreased range of motion

Patients with ankylosing spondylitis show what vertebral abnormality on radiography

Patients with ankylosing spondylitis show vertebral fusion (bamboo spine) on radiography.

What is congenital kyphosis?

People with congenital kyphosis are born with a spine that didn't develop properly before birth. It can get worse as a child grows and typically requires surgery at a young age to stop the curve from progressing

What is the cornerstones of treatment for ankylosing spondylitis?

Physical therapy and NSAIDs are the cornerstones of treatment for AS

Does postural kyphosis usually require surgery or bracing?

Postural kyphosis is easily corrected with education about proper posture, including some retraining on how to sit and stand correctly. Special bracing or casting is usually not necessary. Strengthening exercises for the back muscles can be helpful in correcting posture.

Diagnosis of torticollis?

Radiographs of the cervical spine should be obtained to rule out an obvious bony abnormality. Ultrasonography can be used to visualize muscle tissue and is preferred in newborns. MRI should be considered if there is concern about structural problems or other conditions.

What is the diagnostic test of choice for scoliosis?

Radiographs standing PA and lateral

Diagnosis of spinal stenosis?

Radiographs: standing AP and lateral may show disk space narrowing, osteophyte formation, facet hypertrophy, and degenerative spondylolisthesis. MRI shows spinal stenosis. CT myelogram will show spinal stenosis and is helpful in patients who cannot have an MRI.

What is the gold standard for evaluating and supporting the diagnosis of ankylosing spondylitis?

Radiography is the gold standard for evaluating and supporting the diagnosis of ankylosing spondylitis

What are some red flag that should be of particular concern in a patient presenting with back pain?

Red Flags: Summary (Mnemonic: TUNA FISH, as an aid to documentation) T - Trauma U - Unexplained Weight Loss N - Neurologic findings (includes bowel or bladder Incontinence and other Cauda Equina Syndrome symptoms) A - Age >55 years (or age >65 years) F - Fever I - Immunocompromised S - Steroids H - History of HIV, Tuberculosis, Cancer

Loss of ankle jerk

S1

Loss of sensation on posterior leg/calf and plantar surface of the foot

S1

Sensory loss to POSTERIOR leg/calf and gluteus, PLANTAR (BOTTOM) surface of foot

S1

Walking on toes more difficult than walking on heels

S1

Weakness with plantar flexion, Walking on toes more difficult than walking on heels

S1

Which nerve root does the ankle reflex test?

S1

What are the *borders of the thoracic outlet*?

Scalene muscles, first rib, and clavicle

What is Scheuermann's kyphosis?

Scheuermann's kyphosis is named after the radiologist who first identified the condition. It happens when the vertebrae have a different shape. Instead of being rectangular, the vertebrae have a wedge shape. The wedge-shaped bones curve forward, making the spine look rounded. It presents in childhood, is most common in boys and is diagnosed radiographically by a kyphotic curve with anterior wedging of more than 5 degrees in a minimum of three successive vertebrae

Lateral curvature of spine > 10 degrees

Scoliosis

Scoliosis is associated with what class of lung disease?

Scoliosis is associated with restrictive lung disease

Scoliosis is defined as a lateral spinal curvature with a Cobb angle of _________ degrees or more?

Scoliosis is defined as a lateral spinal curvature with a Cobb angle of 10° or more

Scoliosis is linked with what disorders

Scoliosis is linked with some neuromuscular disorders like cerebral palsy or muscular dystrophy

Pain in elderly that increases with walking and is relieved by leaning forward

Spinal Stenosis

At what two levels does spinal stenosis most commonly occur?

Spinal stenosis most commonly occurs at the L3 to L4 and L4 to L5 interspaces.

What vertebral structures can be felt when palpating the posterior spine?

Spinous process of vertebra

At what spinal curvature should surgery be considered for the treatment of scoliosis?

Surgery if > 40°

Symptoms of torticollis?

Symptoms include a limited range of head motion, headache, or neck pain

Loss of sensation along the ulnar aspect of the forearm

T1

Spinal cord damage below which level will result in paraplegia?

T1

Weakness of finger abductors

T1

A patient complains of loss of sensation at the level of the umbilicus. Which of the following dermatomes is affected?

T10

What is Tinel's test for thoracic outlet syndrome?

Tapping of the *supraclavicular fossa* producing paresthesias

What is the Cobb angle?

The Cobb angle is the measurement between two lines drawn perpendicular to the upper border of the uppermost vertebra, and the lower border of the lowest vertebra involved in the curvature

What is the cardinal sign of spinal cord injury?

The cardinal sign of spinal cord injury is a discrete injury level in which neurologic function above the injury is intact, and function below the injury is absent or markedly diminished

Affects pain and temperature sensation

The lateral spinothalamic tract

What is postural kyphosis?

The most common type of kyphosis, postural kyphosis usually happens during the teenage years. Slouching or poor posture stretches the ligaments and muscles holding the vertebrae in place. That stretching pulls the vertebrae out of their normal position, causing a rounded shape in the spine.

Affects proprioception (position sense) and vibration sense below the level of the lesion

The posterior column

What are the signs of thoracic outlet syndrome?

The signs of thoracic outlet syndrome include: ● Paget-von Schroetter syndrome—venous thrombosis (a.k.a "effort thrombosis") leading to edema, arm discoloration, and distension of the superficial veins ● Weak brachial and radial pulses in the involved arm ● Hypesthesia/anesthesia ● Atrophy in the distribution of the ulnar nerve ● Positive Adson maneuver/Tinel's sign ● Edema

What are the symptoms of thoracic outlet syndrome?

The symptoms of thoracic outlet syndrome include: ● Paresthesia's (neck, shoulder, arm, hand); 90% in ulnar nerve distribution ● Weakness (neural/arterial) ● Coolness of involved extremity (arterial) ● Edema, venous distension, discoloration (venous)

What are the types of kyphosis?

The three most common types of kyphosis are postural kyphosis, Scheuermann's kyphosis, and congenital kyphosis. Kyphosis can also be a result of osteoporotic compression fractures. Tuberculosis of the spine (Pott's disease) will also cause progressive kyphosis.

Affects pressures and touch sensations

The ventral spinothalamic tract

What are the neurovascular structures that traverse the thoracic outlet and can be compressed in TOS?

There are 3 neurovascular structures traversing the thoracic outlet that can be compressed: 1. Subclavian artery ("arterial TOS") 2. Subclavian vein ("venous TOS") 3. Brachial plexus ("neurogenic TOS")

X-ray findings in a patient with postural kyphosis?

There are no noticeable vertebral abnormalities on X-rays because structural damage or deformity does not cause this kyphosis

What are the most common causes of cauda equina syndrome

These are the most common causes of cauda equina syndrome: 1. A severe ruptured disk in the lumbar area (the most common cause) 2. Narrowing of the spinal canal (stenosis) 3. A spinal lesion or malignant tumor. 4. A spinal infection, inflammation, hemorrhage, or fracture

What do you do if no bony C-spine fracture is apparent on CT scan and you cannot obtain an MRI in a COMATOSE patient?

This is controversial; many leave the patient in a cervical collar

What is thoracic outlet syndrome (TOS)?

Thoracic outlet syndrome (TOS) is a group of disorders that occur when blood vessels or nerves in the space between the collarbone and first rib (thoracic outlet) are compressed. This can cause shoulder and neck pain and numbness in your fingers.

What are the three causes of thoracic outlet syndrome?

Thoracic outlet syndrome is usually caused by compression of the nerves or blood vessels in the thoracic outlet. The cause of the compression varies and can include: 1. Congenital anomalies, including cervical rib (an "extra first rib"), abnormal fascial bands to the first rib, or abnormal scalene muscles 2. Trauma—first rib or clavicle fracture, humeral head dislocation, or crush injury 3. Repetitive use/overuse (i.e., baseball pitchers)

What causes torticollis?

Torticollis may occur in congenital and acquired forms. A multitude of conditions may lead to the development of torticollis including minor trauma, viral illness, muscular fibrosis, congenital spine abnormalities, toxic or traumatic brain injury, or use of dopamine-blocking drugs (eg, haloperidol)

What is torticollis?

Torticollis or wryneck refers to lateral twisting of the neck that causes the head to tilt to one side with the chin turned to the opposite side. In Latin, the word "torus" means "twisted" and "collum" means "neck".

What is spinal trauma?

Trauma to the spine may cause injuries involving the spinal cord, vertebrae, or both. Occasionally, the spinal nerves are affected.

Treatment for kyphosis?

Treatment for postural kyphosis and Scheuermann's kyphosis may include regular X-rays to monitor the curve, physical therapy and, in some cases, a back brace: ● Curves of 45 - 60 degrees should be observed every 3-4 months and exercise prescribed for lumbar lordosis ● Curves > 60 degrees or with significant pain should be treated with bracing (Milwaukee brace) ● For congenital kyphosis (and severe Scheuermann's kyphosis with a curve of more than 75 degrees), spinal fusion surgery can relieve pain and correct the curvature.

Treatment of spinal stenosis?

Treatments include medications, such as anti-inflammatories, physical therapy, epidural corticosteroid injections, radiofrequency denervation, and sometimes surgery

Which nerve is most often involved thoracic outlet syndrome?

Ulnar nerve

Describe Kemp sign?

Unilateral radicular pain from foraminal stenosis made worse by extension of the back

Upper extremity weakness, decreased sensation and reflexes, positive spurling test, pain at rest

Usually posterolateral herniation at C5-C6 or C6-C7

Beyond the physical exam what additional testing should be performed in the evaluation of suspected back strain or sprain?

Usually, if the duration of pain is short (< 4 to 6 weeks), no additional testing is required unless red flag findings are present, patients have had a serious injury (eg, vehicular crash, fall from a height, penetrating trauma), or evaluation suggests a specific nonmechanical cause

Treatment of torticollis?

Usually, treat with physical measures, botulinum toxin injection, and/or oral medications (diazepam, muscle relaxants)

What is uveitis?

Uveitis is inflammation of the uvea, the middle layer of the eye between the retina and the sclera (white of the eye)

How do you rule out a C-spine bony fracture?

With a CT scan of the C-spine

In patients with significant lumbar spinal stenosis, does walking lead to worsening or improving leg pain?

Worsening!

Diagnosis of kyphosis?

X-Ray - standing AP and lateral films are diagnostic. Pulmonary function tests whether the kyphosis is affecting breathing - restrictive airway pattern. Kyphosis is defined as a curvature of the spine measuring 50 degrees or greater on an X-ray