MSK - Disorders of the Spine

what describes the spine?

the bones, muscles, tendons, and other tissues that reach from the base of the skull to the tailbone

what surrounds and protects the spinal cord?

the vertebral column

what describes the functions of the spine?

• provides structural support

• protects spinal cord

• transmits forces between upper and lower body

• absorbs mechanical stress during daily activities

how many cervical vertebrae are ther?

7

what describes cervical vertebrae?

smallest and greatest mobility

how many thoracic vertebrae are there?

12

what describes the thoracic vertebrae?

larger, limited mobility, holds the ribs, protects the thorax

how many lumbar vertebrae are there?

5

what describes the lumbar vertebrae?

largest, holds the weight of the body, accomodates axial motions

how many sacral and coccygeal vertebrae are there?

5 + 4 fused vertebrae

what describes sacral and coccygeal vertebrae?

fused and shaped like a shield, serves as the site for many muscle attachments

what describes reasons why the spine is curved?

• improved balance

• energy-efficient posture

• better shock absorption

• more even force distribution

what kind of curvature is present in the fetus and remains in adulthood?

primary curvature

what is associated with primary curvature?

kyphosis and outward curvature

primary curvature is usually associated with what regions?

thoracic and sacral

what develops as the child grows?

secondary curvature

secondary curvature is associated with what?

lordosis and inward curvature

secondary curvature is associated with what regions?

cervical and lumbar regions

what describes hyperlordosis?

excessive inward curvature of cervical or lumbar regions

hyperlordosis is usually what kind of issue?

postural

most cases of hyperlordosis are what?

idiopathic and found in children

what can be secondary to pregnancy, obesity, muscular imbalance, spondylolisthesis, achondroplasia?

hyperlordosis

hyperlordosis is mostly what?

asymptomatic

how can you treat hyerlordosis?

• NSAIDs for associated back pain

• core-strengthening exercise and physical therapy

what describes hyperkyphosis?

excessive forward curvature in thoracic region

what are cause of hyperkyphosis?

postural, Scheuermann’s', congenital, osteoporosis, trauma, tumors

how does hyperkyphosis present?

• with a round back “hunch back”

• may also present with upper back/shoulder pain, stiffness, limited mobility

what describes scheuermann juvenile kyphosis?

a growth-related disorder, typically diagnosed in adolescence (12-17 yo), M>F 2:1

what are risk factors for scheuermann juvenile kyphosis?

• hereditary (possibly a gene involved in vertebral growth and collagen production)

• rapid longitudinal growth (taller boys are at risk for more severe disease)

• participation in competitive sports (frequent flexion and extension of the trunk)

what describes findings on a physical exam that will support scheuermann juvenile kyphosis?

• parents notice a curved back

• spinal deformity with a possible history of back pain

what describes findings on a imaging that will support scheuermann juvenile kyphosis?

• cobb angle >40°

• 3 or more adjacent vertebrae should be affected

what describes Cobb angle?

measurement that quantifies magnitude of spinal deformities

how is cobb angle assesed?

• the upper and lower end vertebrae of the deformity to be measured are identified (these are the vertebrae that have the most tilt)

• lines are drawn parallel to the superior endplate of the upper end vertebra and the inferior endplate of the lower end vertebra

what are complications of kyphosis?

• progressive cosmetic deformity

• chronic back pain

• scoliosis

• neurological deficits with spinal cord compression

what describes treatments for kyphosis?

• physical therapy (strengthens and stretches back muscles)

• NSAIDs

• orthotics for kyphosis >60°

• surgery (spinal fusion ) rarely performed (usually only if kyphosis >75°, persistent severe back pain, neurological complications (cord compression))

for kyphosis and lordosis, what describes the spine on an A /P view?

straight

what describes scoliosis?

lateral curvature of the spine + simultaneous rotation of involved vertebrae

what is the most common structural spinal deformity in adolescents?

scoliosis

scoliosis most commonly manifests between what age?

10-18 years old (F » M)

in the case of scoliosis, 80% of cases are what?

idiopathic

severe scoliosis may cause what?

thoracic restriction → respiratory distress, heart failure

mild scoliosis is typically asymptomatic and identified when?

during a well-child examination

how does scoliosis usually present?

• as chest wall or back asymmetry (back pain in only 1/4)

• uneven shoulders, hips, breasts, waistline

• unilateral scapula protrusion

• spinal curvature C-shaped or S-shaped

• rib prominence

what is the test that can be used during a physical examination for scoliosis?

adam forward bend test

what describes the adam forward bend test?

back exposed, patient bends towards the toes with knees and arms straight + palms touching (lower back and upper back hump will be visible)

what describes abnormal findings on a physical examination that would support scoliosis?

• spinal curvatures (rib humps)

• anatomical asymmetries (uneven shoulders, scapulae, hips, and/or skin folds)

what describes how an x-ray can be used to diagnosis scoliosis?

• x-ray: standing, full length of thoracic and lumbar spine, sacrum, pelvis

• cobb angle evaluated

what is the cobb angle measurement for mild scoliosis?

10-20°

what is the cobb angle measurement for moderate scoliosis?

20-40°

what is the cobb angle measurement for severe scoliosis?

>40°

scoliosis treatments are designed to do what?

limit the progression of the disease

scoliosis treatment usually consists of what?

orthotic management or surgical correction with fusion

cobb angle 20-45° + remaining growth potential indicates what treatment?

brace

cobb angle >45-50° indicates what treatment?

posterior spinal fusion (prevents progression that could lead to compression of thoracic organs)

what is the etiology of congentical scoliosis?

incomplete formation of vertebrae (hemivertebra), failure of separation of vertebrae

when is congential scoliosis usually found?

usually at newborn exam, may present in adulthood in mild cases

how is congenital scoliosis managed?

by observation

what is treatment of congenital scoliosis?

orthotics, surgery

• removal of the hemivertebra, fusion of curved vertebra

• growing rod

what describes Klippel-Feil syndrome?

congenital synostosis of the cervical vertebrae

Klippel-Feil syndrome is defined by what?

fusion of 2 or more cervical vertebrae

• most commonly between C2 and C3 or C5 and C6

what describes the etiology regarding the genetic mutation associated with Klippel-Feil syndrome?

its more sporadic than it is inherited

Klippel-Feil syndrome is associated with what other disorders?

• scoliosis

• Chiari malformation (cerebrum malformations)

• spina bifida

• Sprengel deformity (scapula deformity)

what is the classic triad associated with Klippel-Feil syndrome?

• short neck

• restricted neck mobility

• low posterior hair line

what are other features associated with Klippel-Feil syndrome?

• hearing loss

• genitourinary or cardiovascular abnormalities

when diagnosing Klippel-Feil Syndrome, what is seen on the X-ray?

cervical vertebral fusion, scoliosis

(MRI indicated for patients with neurological symptoms; may revel cord compression of Chiari malformation)

what is treatment of Klippel-Feil Syndrome?

• orthotics: cervical collars, braces, traction in patients without spine instability

• surgery: cervical spine instability, neurological symptoms

the spinal cord is shorter than what?

the vertebral column

since the spinal cord is shorter than the vertebral column, what occurs?

spinal cord segments are not at the same level as their corresponding vertebral segments

• spinal nerves exit their roots and descend for varying distances before reaching their corresponding vertebral exit point

the spinal cord is a continuation of what?

the brain stem and is covered in meninges

the neural crest cells will develop what?

the vertebrae

the neural tube becomes what?

the spinal cord

what is the most common congenital malformations of the central nervous system?

neural tube defects (NTD)

spina bifida develops when?

between the 3rd and 4th weeks of pregnancy (folate)

deficient folate during pregnancy can lead to what?

improper closure of the neural tube in the embryo (typically at a caudal or cranial end)

what is a failure of closure at the caudal end?

spina bifida

spina bifida can be what?

open or closed

what is the most bening spina bifida?

spina bifida occulta

what is the most severe spina bifida?

myeloschisis

spina bifida occulta has what?

no apparent clinical features

what describes clinical features of meningocele?

protrusion of the meninges

what describes clinical features of meningomyelocele?

protrusion of the spinal cord and meninges = severe

meningomyelocele can cause what?

sensory and motor function loss, such as bladder dysfunction and paraplegia

what is the most common neural tube defect?

spina bifida occulta

spina bifida occulta is a vertebral bone defect without what?

herniation

in spina bifida occulta, what remains intact?

spinal cord, meninges, and overlying skin

while spina bifida occulta is usually asymptomatic, what findings may be present at the vertebral defect?

• lumbar skin dimple

• collection of fat

• patch of hair

• normla a-fetoprotein

what are the types of spina bifida that are open defects?

• meningocele

• meningomyelocele

• myeloschisis

all spina bifida open defects have what?

increased a-fetoprotein (detected during pregnancy)

in terms of spina bifida open defects, neurological symptoms vary depending on the location and extent of neuronal damage but include what?

• motor loss

• flaccid paralysis (rare)

• sensory deficits

• bladder and bowl dysfunction

what are other symptoms associated with spina bifida open defects?

• hydrocephalus (common)

• skeletal malformations (club foot, sacral dimpling)

• joint contractures

• back pain

• developmental delays

• cognitive impairment

• progressive neurological symptoms

spina bifida open defects are present when?

following birth (they are visually seen)

what describes treatment of spina bifida?

prophylactic administration of antibiotics and rapid surgical closure of the defect to avoid CNS infections