MB - Back Pain (Part 2)

what are the two (2) most common causes of mechanical back pain?

#1 - lumbar strain #2 - disc protrusion

if a patient is admitted for a positive diagnosis of cauda equina, what labs need to be taken?

- CBC - ESR - BMP - UA - PT, PTT, INR

what are the epidemiology and risk factors associated with cauda equina?

- vertebral fx - osteomyelitis - discitis - epidural abscess - epidural hematoma - lumbar spinal stenosis - central disc herniation - tumors

where does pain often radiate in low back sprains/strains due to sciatic nerve involvement?

buttocks and posterior thighs

you have two patients. one patient (patient A) is being followed by neurosurgery and the other patient (patient B) is being followed by ortho spine. both of these patient increased back pain, but neither of them have an increase or decrease in neurological deficit. which one of these patients needs to be scheduled for emergent surgery? a.) Patient A b.) Patient B c.) neither patient d.) both patients

c.) neither patient

why is bed rest for longer than 24hrs not a good idea in patients complaining of low back sprain/strain?

can lead to chronic pain

what would you diagnose the following patient with? a severe myelopathy (= compression of spinal cord) in the lumbar spinal cord usually caused by a mass lesion.

cauda equina syndrome

what region of the spine most commonly experiences spontaneous reabsorption of herniated discs?

cervical

there is a herniated disc at L4/L5, what muscle is being impacted?

extensor hallicus longus --> weakness in great toe extensor

upon physical exam of a patient with cauda equina syndrome, where would the patient feel tenderness?

focal lumbar spine

a patient comes into your office complaining of midline vertebral tenderness. what am i concerned for?

fracture (vs sprain/strain = paravertebral spinal muscles)

there is a herniated disc at L5/S1, what muscle is being impacted?

gastrocsoleus --> weakness in great toe flexor and gastrocsoleus --> can't tippy toe walk

what is the most common cause of cervical herniated disc nucleus pulposus?

gradual degeneration of the disc

how would a patient develop a spinal abscess/what is the pathophysiology of spinal abscess?

hematogenous spread (originating in blood and spread through bloodstream) to epidural/potential space

the is cross straight leg raise test highly specific or highly sensitive?

high specific

since AP and later lumbar films don't help us to diagnose cauda equina, what emergent imaging is needed and laboratory studies would help us obtain it?

imaging: emergent MRI labs: CBC & ESR to confirm infectious etiology

what vertebral duo is most likely to be affected by spinal stenosis?

in order of likelihood: - L4/L5 - L3/L4 - L1/L2

what plain film would show the following in a pt diagnosed with spondylolisthesis: - slippage of one vertebrae onto another - involved disc - narrowing & degeneration

lateral

what two (2) activities weaken the nucleus pulposus of vertebral discs?

lifting and bending

how is a cross/crossed straight leg raise test performed in order to invoke a positive test to indicate probable disc herniation?

lifting the unaffected leg produces pain in the affected leg

upon physical exam, where would tenderness typically diffuse in patients with a low back sprain/strain?

lower back and SI region

what vertebral region do disc herniations most commonly occur?

lumbar

what is more common: lumbar HNP or cervical HNP?

lumbar HNP

what region of the spine would have decreased range of motion as a result of low back sprain/strain? what movement in particular?

lumbar; flexion

what type of causes are most common in causing back pain?

mechanical - don't typically require imaging - managed with NSAIDs, muscle relaxants, and analgesia

what age demographic is at increased risk of cervical HNP?

men and women (equally) age 40+

what is a high-grade slip when it comes to spondylolisthesis?

more than 50% slippage (...more than 50% of the width of the fractured vertebra slipping forward on the inferior vertebra)

how is proprioception impairment assessed in patients with spinal stenosis?

movement of the big toe

how are myotomes (muscle group innervated by a single nerve root) affected by cervical HNP?

muscle spasms or fasciculations (= muscle twitching)

what is the primary reason for considering early/immediate operative tx of a pt demonstrating profound spinal cord compression from a large herniated disc?

myelopathy (= spinal cord involvement)

what drug, when it's injected in the ER for the treatment of pain, can cause urinary retentions that can be mistaken for cauda equina syndrome?

narcotics

what type of claudication is aggravated by activities like walking, but gets better with rest?

vascular claudication bc it's a circulatory problem rather than a neural one (...neurogenic claudication doesn't get better because the nerves are being impinged)

you have a pediatric patient between the ages of 2-7 who presents to your clinic looking ill. after your medical assistant takes his temperature, she tell you the little girl has a fever. as the patient walks to the exam room, you notice her leaning forward as she walks, with her hands on her thighs. what is she trying to prevent as she supports herself on her thighs as she walks?

psoas sign --> positive psoas sign = pain produced when patient is laying on their side and their leg is pulled backwards

what is the goal when it comes to treating low back sprains/strains?

relieving symptoms

what is surgical decompression?

removing part of the vertebrae in order to decompress/relieve pressure on the spinal cord and/or nerves (ie. laminectomy)

why would the sciatic notch be tender to palpation?

sciatic nerve irritation due to lumbar herniated disc

a patient comes into my office complaining of sciatic nerve pain, where could i palpate on their body to help confirm that diagnosis by reproducing their pain, numbness, and/or tingling?

sciatic notch

where would a patient feel pain if they had a cervical disc herniation in the neck?

shoulder(s) and arm(s)

are patients that have a prior history of low back pain more likely to have exacerbations?

yes

can a spinal abscess lead to cauda equina syndrome?

yes

can spinal stenosis lead to cauda equina?

yes

could AP and lateral plain films be used to diagnose spondylolisthesis?

yes

could a herniated nucleus pulposus cause damage to the spinal cord?

yes

even though cauda equina syndrome affects both legs, can one leg be worse than the other?

yes

is osteoporosis a risk factor for spondylolisthesis?

yes

is spontaneous absorption of herniated discs possible?

yes

should patients diagnoses with spinal stenosis have a surgical consult?

yes

will patients with spinal stenosis have normal physical exams?

yes

would a patient with cervical herniated nucleus pulposus experience decreased grip strength to the point of dropping objects?

yes

would motor and sensory function be normal on a physical exam of someone with low back sprain/strain?

yes

would overuse and hyperextension of the low back cause a stress fracture of the pars interarticularis (spondylolysis)?

yes

would sciatic nerve injury make it more difficult for patients to stand erect?

yes

is cauda equina a surgical emergency? which department should be called?

yes! consult neurosurgery or ortho spine

although discitis can occur anywhere in the spine, which two (2) regions does discitis occur most commonly?

thoracic & lumbar

although muscle weakness of the lower extremities is subtle bc slowly advancing symptoms with spinal stenosis, what activity can be done to elicit it?

treadmill

is radicular pain caused by lumbar herniated nucleus pulposuses typically unilateral or bilateral?

unilateral

what is stabilization?

using small wires or screws to joint both sides of the fractured bone, and secure the vertebra in place. this prevents the fx from progressing further by keeping the vertebra from slipping forward

would exercising and conditioning to improve core strength help patients complaining of low back sprain/strain?

yes, along with other lifestyle modifications in addition to exercise and strength training like diet

will patients with spinal stenosis have sensory and/or motor deficits? if so, where?

yes; at specific nerve root levels

in what direction do most disc herniations occur?

posterolateral

there is a herniated disc at C6/C7, what reflex(es) are impacted?

- triceps - finger extensors

how would a patient with spondylolisthesis appear on physical exam as you assess motor and sensory function?

- L1 to S4 nerve roots - diminished knee and ankle reflexes - weakness in great toe - reduced plantar and dorsiflexion strength --> inability to do heel and toe walks

what three (3) vertebral body pairs does cauda equina affect? *think about the commonality of lumbar herniated nucleus pulposus*

- L4/L5 <--most common - L5/S1 - L3/L4

what special tests can be used to help dx cauda equina syndrome?

- Watch Patient Walk (inability to walk on heels = dorsiflexion weakness; inability to walk on toes = plantarflexion weakness) - Inability to rise from chair without assistance of arm rests (quads/hip extensor weakness) - Anal Wink and Digital Rectal Exam <--decreased rectal tone (evaluates motor and sensory funx of lumbar spine roots) - Post-Void Residual <--urinary retension (>200mL = urinary retention)

elderly patients are at higher risk for what three (3) things when it comes to their back pain?

- abdominal aortic aneurysm (AAA) - fracture - malignancy

there is a herniated disc at L5/S1, what reflexes are being impacted?

- achilles tendon reflex - asymmetric ankle reflex

how would a patient with cauda equina syndrome present in clinic?

- acute or chronic back pain - rapid development of bilateral leg pain - bilateral leg weakness - bilateral leg numbness - saddle paresthesia - urinary retention or incontinence - constipation or fecal incontinence

what are the two (2) risk factors associated with spinal stenosis?

- age 60+ - obesity due to degeneration

what are the red flags and referrals for spinal stenosis?

- any neurological deficit - gait disturbance - bowel/bladder dysfunx

what are the red flags in need of referral for cauda equina?

- any unexplained neuro deficit - loss of normal bowel and/or bladder function - increasing pain not controlled by analgesics (like spinal abscess) - decreasing pain in the presence of increasing neurological deficit - urinary retention = most common finding - loss of rectal tone = late finding that's subtle (like spinal abscess) - perform rectal exam if pt sxs worsen

besides gradual degeneration of the disc, what would cause cervical herniated nucleus pulposus?

- attenuation/weakening of the posterior annulus fibrosis (aka weakening of outer layer of disc) - subsequent protrusion of the nucleus pulposus into the spinal canal causing compression of the nerve root

there is a herniated disc at C4/C5, where does the patient feel pain?

- base of neck - shoulder - anterolateral arm

there is a herniated disc at C5/C6, what reflex(es) are impacted?

- biceps - brachioradialis

there is a herniated disc at C4/C5, what muscles does the patient experience motor weakness or atrophy?

- biceps - deltoid

there is a herniated disc at C5/C6, what muscles does the patient experience motor weakness or atrophy?

- biceps - wrist extensors - pollicis longus

what diagnoses are associated with night time back pain?

- cancer - low back sprain/strain - lumbar HNP --> pillow under knees or fetal position on side - spinal stenosis

where can discitis secondary involvement occur? how does it appear on x-ray?

- cartilaginous end plates - vertebral bodies bright white

what are the possible red flags of lumbar disc herniation that would need referral?

- cauda equina - urinary retention - perianal numbness - motor loss - severe single nerve root paralysis - progressive neurologic deficits - radicular sxs >6wks - intractable leg pain - recurrent episodes that interfere with activities of daily living (ADL's)

how would a patient with spondylolisthesis appear on physical exam as you inspect and palpate their spine?

- curvature - loss of lordosis (= excessive curvature of lumbar spine) --> straightening of lumbar spine - step-offs of spinous processes allows palpation of disc slips

what are risk factors for patients developing spinal abscess?

- diabetes - IV drug use - chronic renal failure - alcoholism - immunosuppression - recent procedure

low back pain is exacerbated in which types of patients and why?

- elderly --> deep conditioning - drivers --> obesity and poor diet

what diagnoses should be of concern to immunocompromised patients complaining of back pain because they're at higher risk?

- epidural abscess - osteomyelitis - discitis

what are the red flags seen in cervical HNP that would warrant a refferal?

- failure of non-operative tx - muscular atrophy - motor weakness - signs of myelopathy (requires sx) - signs of demyelination - tumor/infection - intolerable radicular symptoms

what five (5) symptoms would cause for a follow-up in patients who originally cam in for low back sprain/strain?

- fever - bowel & bladder dysfunction --> cauda equina - paresthesias --> sciatic nerve involvement via inflammation/compression - persistent, non-improving pain

patients with these two (2) conditions should not be given NSAIDs:

- gastritis - renal/kidney dysfunction

what two (2) events can cause acute onset low back pain?

- heavy lifting - repetitive movement

what three (3) things can a plain x-ray NOT show?

- herniated disc - cartilaginous discs - spinal nerves

what are the paravertebral spinal muscles that when injured can produce low back sprain or strain?

- iliocostalis - longissimus - spinalis

what are two (2) types of patients who are at an increased risk for developing discitis?

- immunocompromised - pts w/ systemic infections

there is a herniated disc at C6/C7, where is sensation affected?

- index finger - long fingers - dorsum of hand

if labs were to be taken on a patient complaining of low back sprain/strain, what would they be and why?

- urinalysis (UA) --> r/o infection - urine HCG --> r/o pregnancy

lumbar herniated disc may cause the following symptoms:

- intermittent or continuous back pain (may be made worse by movement, coughing, sneezing, or standing for long periods of time) - spasm of the back muscles - sciatica (= pain that starts near the back or buttock and travels down the leg to the calf or into the foot) - muscle weakness in the legs - numbness in the leg or foot - decreased reflexes at the knee or ankle - changes in bladder or bowel function - difficulty walking (ddx = cauda equina) - incoordination

what three (3) movements can cause low back sprain/strain?

- leaning - bending - twisting

what should you expect to see upon physical examination of a patient with cervical HNP?

- loss of cervical lordosis - decreased range of motion of neck - arm & shoulder pain caused by extension and axial rotation

what diagnoses will have normal physical exams?

- low back sprain/strain - spinal stenosis

what diagnoses produce a positive straight leg raise test?

- lumbar herniated disc - discitis - cauda equina (maybe)

what two diagnoses causes pain to radiate down the buttocks to the posterior/posterolateral leg down to the ankle or foot?

- lumbar herniated disc - sciatic nerve inflammation = buttocks, then to their posterior thigh, then wraps around their leg (posterolateral dorsum of leg), and finally goes down to their foot (lateral malleolus to lateral dorsum of foot and the entire sole)

what diagnoses is the loss of deep tendon reflexes (DTRs) attributed to?

- lumbar herniated nucleus pulposus - cauda equina syndrome

what diagnoses are attributed to bladder and bowel dysfunction?

- lumbar herniated nucleus pulposus - late sxs of spinal abscess (+ decreased rectal tone due to myelopathy) - cauda equina - spinal stenosis

there is a herniated disc at C6/C7, where does the patient feel pain?

- neck - shoulder - medial border of scapula - lateral arm - dorsal forearm

there is a herniated disc at C5/C6, where does the patient feel pain?

- neck - shoulder - medial border of scapula - lateral arm - radial forearm

what are three (3) red flags that could call for a referral?

- neurological deficit - unresponsiveness to analgesia - worsening pain

what are the four (4) approaches to the majority of the red flags of back pain?

- not improved with adequate meds - consider cauda equina/cord syndrome - require aggressive diagnosis and treatment - MRI & ortho spine/neuro surgery consult

what are the vertebral discs composed of?

- nucleus pulposus = gel - annulus fibrosus = ligamentous structure surrounding nucleus pulposus

there is a herniated disc at L5/S1, where are the numbness and pain being felt?

- numbness @ lateral foot - pain/ache @ posterior calf

there is a herniated disc at L3/L4, where are the numbness and pain being felt?

- numbness @ shin - pain @ thigh

there is a herniated disc at L4/L5, where are the numbness and pain being felt?

- numbness @ top of foot & 1st web space - pain @ posterolateral thigh & calf

what patients are in need of plain films, usually AP and lateral films?

- pain for more than 4-6 weeks - elderly - IVDU - significant trauma - pain at rest/night --> could be cancer

there is a herniated disc at L3/L4, what reflexes are being impacted?

- patellar reflex - asymmetric knee reflex

although discitis can occur spontaneously, what are three (3) other possible causes?

- post-sx - dental work - spinal injections

what two (2) things can x-rays be used to show when it comes to cervical HNP?

- regions of spondylosis - degenerative involvement of disc and facet joints

what diagnoses cause a decrease in rectal tone?

- spinal abscess - cauda equina

what diagnoses involve myelopathy?

- spinal abscess - cauda equina - large cervical herniated disc

what diagnoses need sx for decompression?

- spinal abscess - cauda equina ... - spondylolisthesis (for severe pain) - spinal stenosis (last resort!)

paraplegia can be caused by what diagnoses?

- spinal abscess (and quadriplegia due to spinal abscess myelopathy) - cauda equina --> symmetric paraplegia

what two diagnoses are Williams Flexion Exercises a part of the treatment plan? what diagnosis McKenzie Extension Exercises a part of the treatment plan?

- spndylolisthesis - spinal stenosis - lumbar herniated nucleus pulposus

what diagnoses cause patients to have an inability to walk on both their heels and toes due to weakness during dorsiflexion (heels) and plantarflexion (toes)?

- spondylolisthesis - cauda equina

what can be seen on AP and lateral plain films taken for spinal stenosis?

- spondylolisthesis - narrowed disc space

what diagnoses are often associated with spinal stenosis?

- spondylolisthesis - osteoarthritis of hips

what diagnoses have HPIs associated with neurogenic claudication?

- spondylolisthesis - spinal stenosis

what diagnoses are typically degenerative in nature?

- spondylosis --> of spine due to aging - spondylolisthesis --> of discs - cervical HNP --> of discs - spinal stenosis

what two special tests can be used to help diagnose lumbar herniated nucleus pulposus?

- straight leg raise test --> lumbar nerve root compromise - cross/crossed straight leg raise test --> probable herniated disc

what DO the AP and lateral films taken for cauda equina help us to identify?

- structural problems - fractures - spondylolisthesis

there is a herniated disc at C6/C7, what muscles does the patient experience motor weakness or atrophy?

- triceps - finger extensors

1.) what is the treatment plan for spinal stenosis? 2.) is surgery a treatment option? 3.) what tx option is reserved for pts with severe signs and symptoms of spinal stenosis who aren't candidates for sx?

1.) - Williams Flexion PT Exercises that focus on flexing the spine, thus increasing range or motion and reducing pain - exercise to improve abdominal muscles - weight loss to reduce abdominal fat - NSAIDs - vitamin B supplement (especially diabetic pts bc metformin related to B12 deficiency) - folic acid supplement 2.) surgery for decompression is a treatment option, but only as a last resort 3.) long-term pain meds

you have a patient arrive at your office complaining of upper extremity pain and parasthesia. you perform a Spurling Test to diagnose the patient. 1.) what do you diagnose the patient with? 2.) what diagnostic imaging do you order? 3.) why might nerve conduction studies be performed? 4.) what laboratory studies are you ordering? 5.) what would you recommend for treatment for this patient?

1.) cervical herniated nucleus pulposus 2.) MRI (bc disc herniation don't appear on x-ray, only MRI and sometimes CT, and the plain films will show age appropriate degeneration) 3.) locate region of neurological dysfunction & pre-op planning 4.) none usually ... but pre-op base labs could be CBC, BMP, Pt & PTT & INR, type and screen, UA, and HCG 5.) nothing bc spontaneous resolution at 6-12 weeks orrr PT or short-course steroids (even non-narcotic pain meds or short-course narcotics, be careful with long-term narcotic use bc increased risk of chronic pain)

you have a patient come into your office looking ill. while taking a thorough history, you learn your patient recently had dental work done. upon physical examination, you notice point tenderness as you percuss and palpate. you also notice overlying cellulitis and inflammation on the patient's body. you order the following labs: CBC w/ diff, blood cultures, and BMP (additional) for safe measure. the patient's ESR and CRP are both elevated. the blood culture comes back positive for staph aureus. 1.) what are you diagnosis this patient with? 2.) what diagnostic imaging are you ordering following the lab results of elevated ESR and CRP? 3.) are you going to consult orthopedics? 4.) what medications are you going to give the patient, keeping in mind MRSA? 5.) how long are you planning to give your pt these medications? 6.) are you recommending sx for this pt? 7.) what is the prognosis for this patient?

1.) discitis 2.) MRI to see inflammation (bc x-rays aren't sensitive and appear normal for the first 2-4 weeks of infection similar to osteomyelitis) 3.) yes 4.) IV abx (dicloxacillin for bacteria sensitive to oxacillin and nafcillin which are all penicillinase resistant antibiotics) + cephalosporin 5.) IV abx = 2-4 days; oral = 4-6wks 6.) no, it's almost never required 7.) good unless the pt develops osteomyelitis

your patient comes into your office with complaints of motor dysfunction in the extensor hallicus longus which is causing weakness of the great toe extensor. the patient mentions experiencing numbness on the top of his foot and first (1st) web space as well as pain in his posterolateral thigh and calf. 1.) what do you diagnose the patient with? 2.) where is the issue located? 3.) what diagnostic imaging are you ordering to confirm your diagnosis? 4.) what labs are you ordering? 5.) what medications are you prescribing in the acute phase? 6.) how long do you want the patient to be on bed rest? 7.) what movements do you want the patient to limit? 8.) what treatments would you recommend if the symptoms persist? 9.) what PT exercises would you recommend the patient do?

1.) lumbar herniated nucleus pulopsus 2.) L4/L5 3.) MRI 4.) none unless we need to r/o UTI via UA and pregnancy via urine HCG 5.) NSAIDs, muscle relaxers 6.) 1-3 days 7.) sitting, prolonged standing, and walking 8.) short course oral steroids or epidural steroid injections 9.) McKenzie Extension exercises

you have a patient come into your office complaining of difficulty heel and toe walking (reduced plantar and dorsiflexion strength). when you assess the patient's motor function, you realize they have diminished knee reflexes & ankle reflexes, and weakness of the great toe. you also notice the patient has some loss of curvature in the lumbar spine (loss of lordosis) and spinal process step-offs. 1.) what are you diagnosing this patient with? 2.) what diagnostic imaging are you ordering? 3.) what labs are you ordering? 4.) what PT exercises are you recommending? 5.) what brace are you putting the patient in? 6.) what movements do you recommend the patient limit? 7.) what medications are you prescribing? 8.) are you recommending surgery for this patient?

1.) spondylolisthesis 2.) AP, lateral plain films 3.) none, unless sx 4.) William Flexion exercises 5.) corset brace 6.) repetitive bending, lifting, and twisting 7.) NSAIDs then injections 8.) if the pain is severe: MRI, surgical decompression, or stabilization

at what age does spinal stenosis usually occur?

60's

what vertebral bodies should be assessed for motor reflexes and sensory function in patients diagnosed with cervical herniated nucleus pulposus?

C5 - T1

what vertebral bodies should be assessed for motor reflexes and sensory function in patients diagnosed with spondylolisthesis?

L1 - S4

cauda equina syndrome can cause motor and sensory deficits. in what distribution would it appear?

L4 - S5 (--> L4/L5 = most common; also L5/S1 & L3/L4)

there is a herniated disc at L3/L4, what reflex is being impacted?

L4 dermatome

what are the most common vertebral bodies to have spondylolisthesis? what are the second most common vertebral bodies to have spondylolisthesis?

L4/L5 --> L4 slips over L5 (70%) L5/S1 --> L5 slips over S1 (25%)

we know disc herniations occur most often in the lumbar spine, but where exactly in the lumbar spine are the two (2) most common disc spaces where disc herniations occur?

L4/L5 and L5/S1

although spondylolysis can be (usually incidentally) found on any level, what vertebral body does it most commonly involve?

L5

what nerve roots are stretched during the straight leg raise test (30-70 degrees reproduces radicular numbness and tingling/paresthesia in affected leg that's being raised)?

L5 & S1

there is a herniated disc at L4/L5, what dermatome is being impacted?

L5 dermatome

a disc protrusion at L4/L5 would compress the ___ nerve root. a disc protrusion at L5/S1 would compress the ___ nerve root.

L5; S1

since x-rays aren't helpful in diagnosing lumbar herniated nucleus pulposuses, what diagnostic imaging is helpful to the point it can actually confirm dx of LHNP?

MRI

what is the diagnostic imaging/test of choice when it comes to diagnosing disc herniations and defining the disc injury?

MRI

what is the first line imaging for spinal stenosis? explain why. what is second line imaging for spinal stenosis?

MRI bc it shows diameter of stenosis and amount of cord compression CT

there is a herniated disc at L5/S1, what dermatome is being impacted?

S1 dermatome

what test could be used to help diagnose cervical radiculopathy as a result of cervical herniated nucleus pulposus? what would a positive test look like?

Spurling Test --> patient tilts head backwards (extension of neck) and rotates their head to the side where the pain is felt, while the provider is pushing down on the top of the patient's head. positive test = reproduction of cervical radiculopathy producing pain and/or paresthesia of upper extremity/arm

what exactly is the pars interarticularis?

a small, thin segment of bone (isthmus) that joins the facet joints of two vertebrae (superior and inferior) in the posterior spine

what bug is most commonly the cause of discitis? a.) staphylococcus aureus b.) gram negative c.) fungal d.) TB

a.) staphylococcus aureus

there is a herniated disc at L3/L4, what muscle is being impacted?

anterior tibialis --> weakness of anterior tibialis muscle

where would radicular pain be noticed in a patient diagnosed with cervical HNP? how would it feel?

arm pain, numbness (parasthesia), and/or weakness

the nerve root that gets compressed during disc herniations is the root that exits the foramen ___ the herniated disc.

below

there is a herniated disc at C4/C5, what reflex(es) are impacted?

biceps

when conducting physical exam, be alert to ___ & ___ dysfunction due to urinary and bowel ___ and ___.

bowel & bladder; incontinence and retention

a patient comes into your office complaining of occipital headaches, pain in the paraspinal muscles (iliocostalis, longissimus, and spinals), and pain in the scapular region. what are you possibly diagnosis this patient with? this patient also says his neck pain and radicular pain to his upper extremities is improved by placing his hands on his head. why might that be?

cervical HNP (low back sprains/strains also involve the paraspinal muscles) decreased tension on nerve root

we know that herniated nucleus pulposuses most commonly occur in the lumbar vertebrae, but what other vertebral regions could they occur?

cervical and thoracic

a patient has the following symptoms: - decreased grip strength - lack of coordination - decreased fine motor skills - changes in handwriting what diagnosis is at the top of your differentials list for this patient?

cervical herniated nucleus pulposus

cauda equina syndrome is caused by the compression of ___ ___ or spinal nerve roots compromising the cauda equina.

conus medullaris

a patient with spondylolisthesis would complaint of back pain with which of the following movements? a.) bending b.) lifting c.) twisting d.) all the above

d.) all the above

cauda equina syndrome's motor/sensory deficits include which of following? a.) genitals b.) perineum c.) rectum d.) all the above

d.) all the above

which of the following is true in regards to special exams of spinal stenosis? a.) reflexes can be diminished b.) can have lumbar scoliosis c.) may have bowel and bladder decrease in sphincter tone d.) all the above

d.) all the above

why are NSAIDs effective in the treatment of low back sprains/strains?

decrease inflammation

cauda equina syndrome causes a ___ GI motility, leading to constipation. it can also make it harder for the ___ muscles to squeeze and empty itself.

decrease; bladder

what is spondylolysis?

defect in pars interarticularis between superior and inferior facet joints that cause a stress fx

what is spinal stenosis?

degeneration causing narrowing of spinal canal with compression of spinal nerves on a single or multiple levels

why are women 40+ at higher risk of spondylolisthesis?

degenerative changes in disc + menopause & osteoporosis thins bones

what is spondylosis?

degenerative changes of spine bc of aging

how might a patient with a lumbar herniated disc describe their sleeping habits?

difficulty finding a comfortable position - lying on back with pillow under knees - fetal position on side

what are you suspicious of if a patient report their lower back pain disappearing when their leg pain begins?

disc herniation

you have a pediatric patient between the ages of 2-7 who presents to your clinic looking very ill as his mom tells you he's experiences fever and chills. when you ask the patient to point to where he feels his pain, he points to his thoracic region, localizing the moderate to severe pain. the patient's mom says he's pain is worse with movement, and he feels some radicular paresthesia due to the inflammation effecting the nerves in his thoracic region. the patient refuses to walk or sit unsupported by his mom. upon physical examination you document the patient's resistance to passive spinal motion and refusal to elevate his lower extremities, resulting in a rigid back and hips. what diagnosis is at the top of you differential list?

discitis (of thoracic region)

there is a herniated disc at C5/C6, where is sensation affected?

dorsolateral 1st and 2nd fingers (thumb & index finger)

when does vertebral body slippage occur most often in children?

during periods of rapid growth (ie. adolescent growth spurt)

which of the following is true about spinal stenosis? a.) onset can be insidious, or caused by lifting or trauma b.) walking causes significant leg pain, and numbness of the leg and foot c.) neurogenic claudication causing radiculopathy with or without back pain AND in one leg or both legs d.) walking and prolonged standing cause weakness and fatigue in lower extremities e.) all the above

e.) all the above

which of the following would count as more seriour etiologies of back pain? a.) immunosuppressed b.) elderly c.) posttraumatic d.) IVDU e.) all the above

e.) all the above

what should always be considered in back pain of women and pregnant women?

ectopic pregnancy (pain can come from placental abruption)

does heavy lifting and heavy machinery use lessen or exacerbate low back pain?

exacerbate

occasionally patients with spondylolisthesis will experience radiculopathy (= nerve root compression/pinching producing pain, weakness, and numbness in distribution of nerve) and neurogenic claudication. Describe why neurogenic claudication occurs and how it differs from vascular claudication.

neurogenic claudication = occurs due to slipping and narrowing causing compression of spinal nerves located in the lumbar spine. it's typically caused by spinal stenosis (= narrowing of spinal canal) - intermittent leg pain - painful cramping and weakness in legs - doesn't get better bc nerve impingement vascular claudication = stems from circulatory problem; occurs with walking and activity but gets better with rest

do patients typically feel focal point or midline tenderness with low back sprains/strains?

no

should labs be taken on a patient in order to diagnose spinal stenosis?

no

will AP and lateral lumbar films help us make a dx of cauda equina syndrome?

no

are x-ray plain films helpful in diagnosing lumbar herniated nucleus pulposuses?

no because they just show age appropriate changes

are plain films helpful in diagnosing low back sprains/strains? why or why not?

no because typical changes due to age will be seen

pediatric patients are more likely than adults to present with what type of back pain?

non-mechanical (ie malignancy, discitis, spondylolisthesis, scoliosis)

there is a herniated disc at L4/L5, what reflex is being impacted?

none

what labs would you order for lumbar herniated nucleus pulposuses?

none usually, but... - UA and urine HCG = r/o UTI and pregnancy - CBC, BMP, PT & PTT & INR (to see how long it would take for the blood to clot) pre-sx

are labs needed for low back sprain/strain?

not usually

discitis is an infection of what part of the vertebral disc?

nucleus pulposus

there is a herniated disc at C4/C5, where is sensation affected?

numbness in deltoid region

what x-ray view is best to see the scotty dog with a stress fracture collar? what spinal disorder is this?

oblique; spondylolysis

what disease can discitis lead to and why?

osteomyelitis (= infection of bone)

where would a patient feel radiated pain if they had a lower back disc herniation?

pain radiating down into hip(s) and leg(s)

how would a bulging disc into the lumbar canal present in clinic?

pain, numbness, and weakness of one or both legs (usually unilateral)

when looking at an x-ray of your patients spine, you notice a structure that looks like a "scotty dog". what is this structure? the longer you look at the xray, the more you notice the scotty dog appears to have a collar. what does this mean? based on the x-ray imaging described above, what would you diagnose your patient with? based on your diagnosis, how would you treat your patient?

pars interarticularis stress fx (of the pars interarticularis) spondylolysis - activity modification - NSAIDS - PT

physical examination of a patient #1 shows the following: - loss of lordosis of the lumbar spine 1.) what are you possibly diagnosing this patient with? 2.) what vertebral bodies should be assessed for motor reflexes and sensory function? physical examination of a patient #2 shows the following: - loss of lordosis of the cervical spine 1.) what are you possibly diagnosing this patient with? 2.) what vertebral bodies should be assessed for motor reflexes and sensory function?

patient #1: spondylolisthesis & L1-S4 patient #2: cervical herniated nucleus pulposus & C5-T1

in what age demographic is discitis most common? from what age to what age?

pediatric pts ages 2-7

what can happen if cauda equina is not recognized and corrected immediately?

permanent neurological damage and dysfunction

what are the similarities and differences between discitis and spinal abscess?

similarities: - most common bug = staph aureus (gram neg, fungal and TB for discitis and aerobic, anaerobic strep, e.coli, and pseudomonas for spinal abscess) - severe and localized back pain (moderate to severe for discitis) - fever, sweats, and chills (severe chills for spinal abscess = rigor) - radicular sxs (worsen with disease progression for spinal abscess; nerve inflammation for discitis) - spinal tenderness - physical exam signs similar to cauda equina - plain films are normal unless osteomyelitis (OM) present therefore labs are usually normal for the first 2-4wks - MRI is best to confirm dx - order CBC w/ diff, ESR and CRP elevated, blood cultures, and BMP (plus UA and PT, PTT, and INR for spinal abscess) - increased risk in immunosuppressed and pts with recent procedure/sx procedure (also systemic infections for discitis and diabetes, IVDU, chronic renal failure, and alcoholism for spinal abscess) - abx for treatment (empirirc abx for spinal abscess, and IV abx + cephlasporin and then oral abx for discitis) differences: - late signs and symptoms of spinal abscess = bowel & bladder dysfunction, and weakness due to pressure on spinal cord - discitis most commonly occurring in pediatric population - infection in nucleus pulposus for discitis and infection/pus in epidural space - myelopathy (= spinal cord involvement) causing decreased rectal tone, paraplegia, or quadriplegia for spinal abscess - discitis may lead to osteomyelitis (OM) - red flag = increased back pain not controlled by analgesia for spinal abscess - no sx for discitis and urgent sx for decompression for spinal abscess; ortho consult for discitis and sx consult for spinal abscess - prognosis = good for discitis and guarded w/ possible drug rehab for spinal abscess - warmth and erythema = spinal abscess

what activities make disc herniation pain worse?

sitting, walking, standing, coughing, and sneezing

___ and ___ infections are the most common identified source of spinal abscesses.

skin and soft tissue infections

what is spondylolisthesis?

slippage of the anterior portion of the superior vertebral body forward on the inferior vertebral body

low back sprain/strain pain can be presumed to be ___ and ___ inflammation.

spasm; ligament

a diabetic patient has a focal suppurative (pus) infection in the spinal epidural/potential space. what does this patient have?

spinal abscess

what diagnosis causes pain at night due to sleeping on back with legs extended?

spinal stenosis

for what diagnosis does leaning forward help with the pain?

spinal stenosis in order to decrease nerve compression - leaning forward in pediatric patients is a sign of discitis in an attempt to prevent psoas sign - leaning can cause low back sprain/strain

how is spondylolisthesis graded and on what scale?

spondylolisthesis is graded based on degree of slippage: grade 1: <25% grade 2: 25-50% grade 3: 50-75% grade 4: >75%

what is it called when there is a stress fracture through the pars interarticularis?

spondylolysis

stress fx of pars interarticularis = ___ stress fx of pars interarticularis + anterior slippage of superior vertebral body on inferior vertebral body = ___

spondylolysis spondylolisthesis

spondylolysis can lead to spondylolisthesis, so it makes sense that ___ most commonly affects L5 and ___ most commonly affects L4/L5 & L5/S1. it also makes sense that 95% of disc herniations occur at __/__ & __/__.

spondylolysis; spondylolisthesis; L4/L5 & L5/S1

what bug is most likely to cause spinal abscess?

staph aureus (the bugs are aerobic, anaerobic strep, e.coli, and pseudomonas; sometimes the bugs are unidentifiable)

what is the ear of the scotty dog? what is neck of the scotty dog? what is the front foot of the scotty dog? what is the space between the superior scotty dog's foot and the inferior scotty dog's ear?

superior facet pars interarticularis inferior facet facet joint