Spine Patho

Herniated nucleus pulposus (HNP), Spondylosis, spondylolisthesis, spondylolysis, scoliosis, kyphosis, vertebral compression fracture, ankylosing spondylitis, tumors

What are the many causes are spinal stenosis?

Spinal stenosis

Nerve compression caused by narrowing of spinal cord or neural foramina that can occur along any area of the spine (cervical, thoracic, lumbar)

Central Stenosis

Compression of the spinal cord itself

Lateral stenosis

Compression of nerve root as it exits spinal canal - many accompany central

Exacerbation of pain when walking or relief of pain when leaning forward (neurogenic claudication), radiculopathy

Signs of spinal stenosis

Get good upper/lower extremity, R/o compressive neuropathy, Keep an eye out for cauda equinia

Must Haves for Spinal Stenosis exams

Cauda Equina

The bundle of spinal nerve roots at the end of the spinal cord (conus medullaris) in the lumbar region that include the sacral plexus that provides motor/sensory to the lower extremities and also bladder and bowel function

Severe low back pain, radiating pain down the leg, asymmetrical LE motor weakness and/or sensory loss (more than 1 nerve root), loss of reflexes in the LE (hypoactive), sensory loss seen around the anus, lower genitalia, perineum, buttocks, and posterior inner thigh (L3-L5), onset of bowel incontinence, bladder dysfunction (urinary retention or incontinence), recent onset of sexual dysfunction

Red Flags for Cauda Equina Syndrome (CES)

Large herniated lumbar disc, tumor, trauma, spinal epidural hematoma, infection

Possible etiology of CES

urinary retention (anal sphincter tone is only diminished 50-75%)

The most consistent sign in cauda equina syndrome (confirm with MRI)

Prompt surgery within 24-48 hours of presentations, PT (strength, ROM, bracing), Chronic pain medications, lifestyle modifications

Treatment plan for CES

extent of nerve damage, relation to length of time nerve was compressed, cause of compression

Prognosis of CES treatment depends

lumbar spine (L4/5, L5/S1, C4/5, C5/6 - but can happen anywhere)

The most common area to have HNP is in the

Annulus fibrosis (outer layer)

Disc herniation occurs when the __________ breaks open or cracks allowing the nucleus pulposus in escape

repetitive movements, bad posture, being overweight, heavy lifting, disc dehydration

Causes of HNP

X-ray (r/o other causes), MRI (🏆, CT if MRI C/I)

65 y/o male presents to the clinic for back pain that radiates down his legs. On physical exam you note weakness of the legs, patellar reflexes are +1 and pain is exacerbated by extension of the back. What diagnostics do you want?

Pain meds or therapies (u/s, massage, TENs), NSAIDs, PT, Rest, steroid injections (epidural steroid inject - last ditch effort)

65 y/o male presents to the clinic for back pain that radiates down his legs. On physical exam you note pain is exacerbated by extension of the back. MRI reveals a herniated disc at the L4/5 level. What is your conservative management?

Surgical treatment (discectomy - may include laminectomy/laminotomy, or foraminotomy) Note: does not repair/reverse nerve damage

65 y/o male presents to the clinic for back pain that radiates down his legs. On physical exam you note weakness of the legs, patellar reflexes are +1 and pain is exacerbated by extension of the back. What is your management plan?

Spondylosis (osteoarthritis, degenerative disc disease (DDD))

The result of degenerated discs and other cartilage and formation of osteophytes on the vertebrae usually caused by the normal wear-and-tear of aging (middle-age or elderly)

neck stiffness, pain, HA, pain in the shoulder/arm, inability to turn/bend the neck, grinding noise/sensation, improve with rest and are most severe in the morning, if bone spurs press against spinal nerves then weakness, abnormal reflexes, or arm pain

Signs and Symptoms of CERVICAL spondylosis

Lower back pain/stiffness, hip or leg pain, pain worsened with activity, improve with rest, most severe in the morning, if bone spurs press against spinal nerves then weakness, abnormal reflexes, or leg pain

Signs and Symptoms of LUMBAR SPONDYLOSIS

Xrays (if worried about nerves do MRI)

1st line imaging for spondylosis 🏆

rest, nsaids, PT, weight loss, ESI/facet steroid injection

Homies with spondylosis WITHOUT nerve compression → treatment plan

laminectomy/laminotomy, foraminotomy → Cervical fusion, lumbar fusion (for stabilization)

Homies with spondylosis WITH nerve compression → treatment plan

Spondylolysis

A fracture through the pars interarticularis (weakest portion) that can occur on 1 or both sides of the bone (usually L4 or L5)

Spondylolisthesis

Where a bone in the spinal vertebra slips position (anterior or posterior usually lower back) that are graded based on the slippage - common with bilateral spondylolysis

Overuse (sports with hyperextension), Genetics, MVC,

Common causes of Spondylolysis

Congenital (dysplastic Spondylolisthesis), repetitive trauma (isthmic Spondylolisthesis), degenerative (old people), traumatic, bone abnormalities (pagets, TB, tumors)

Common causes of Spondylolisthesis

Standing X-rays with flexion/extension views (spondylolisthesis) or oblique (spondylolysis), MRI for nerve stuff

16 y/o male football player presents to the clinic for low back pain that radiates down to the back of the thighs and is exacerbated by activity. On physical exam you note increased lordosis. What diagnostics do you want?

Referral to ortho spine, activity modification, PT (🔑), bracing to allow fracture to heal, ESI

16 y/o male football player presents to the clinic for low back pain that radiates down to the back of the thighs and is exacerbated by activity. On physical exam you note increased lordosis. X-rays reveal spondylolisthesis. What is your treatment plan?

Spinal stabilization via posterior fusion

16 y/o male football player presents to the clinic for low back pain that radiates down to the back of the thighs and is exacerbated by activity. On physical exam you note increased lordosis. X-rays reveal spondylolisthesis. Your conservative treatment FAILED and now he has weakness, decreased sensation and reflexes what do you want to do now?

Kyphosis (hunchback)

An increased CONVEX curvature (over 45 degrees) of the thoracic spine usually seen in the elderly population with compression fractures or idiopathic (Scheurmann’s disease/juvenile)

Standing lateral x-rays

Imaging for Kyphosis

Repeat X-rays q3-4 months, PT, if over 60 degrees or with persistent pain (Milwaukee brace), Brace them kids, Surgery (if refractoy)

Treatment for Kyphosis

thoracic spine

Most common area for vertebral fractures

Compression fracture

A fracture commonly associated with osteoporosis and NO neuro compromise (stable)

Burst fracture

A fracture usually associated with trauma (MVC, fall from height) and possible neuro compromise (unstable)

Pathologic fractures

Fractures that occur secondary with secondary other diseases

Anterior (looks like a wedge)

Compression fractures usually happen on the ________ aspect of the vertebrae

sudden midline back movement, worse with movement, kyphosis

Symptoms of compression fractures

Xray, MRI (water content with bony edema → shows acute), CT

Imaging for compression fractures

Education on nutrition/exercise, Vitamin D/Ca, Osteoporosis treatments, pain meds, Surgery (IF 50%+ of vertebral height (Kyphoplasty))

Treatment plan for compression fractures

anterior AND posterior aspect (high risk of spinal cord compromise)

With a burst fracture, where does the vertebra lose height?

Significant comminution, severe loss of vertebral body height, excessive angulation at the injury site, significant nerve compression

Treatment of Burst fractures is usually surgical, what are some indications

Ankylosing Spondylitis (seronegative spondyloarthropathy)

An inflammatory disease that over time causes the “fusion of the vertebrae” which can lead to a hunched forward position that begins in the 30-40s (men > women)

Affects the SI joints symmetrically and the spine in a progressively ascending patterns

Describe the pattern of Ankylosing Spondylitis

limited ROM of back, shoulders, hips; kyphosis, synovitis of knee, plantar fasciitis, achilles tendinitis, Schober’s test (tests spine mobility - lumbar flexion)

Physical exam findings on Ankylosing Spondylitis

Uveitis, cardiac abnormalities (1st degree AV block, widened QRS), interstitial lung disease

Extra-Articular Manifestations of Ankylosing Spondylitis

Elevated CRP and ESR, HLA-B27 positive

Labs for Ankylosing Spondylitis

BAMBOO appearance 🎍, sacroiliitis may be an early finding, fractures are common due to fusion

Imaging findings of Ankylosing Spondylitis

PT, NSAIDs, Surgery for any fractures or stabilization

Treatment for Ankylosing Spondylitis

Winking owl sign

Since the spine is a common metastasis point, what is an early sign on the AP view