IT IS THE ULTIMATE ORTHO REVIEW

what population is most likely to seek care for neck pain?

younger females are more likely to seak treatment

age and male were negatively associated with PT use

Which imaging modality does not use radiation?

Diagnostic ultrasound tests

VINDICATE

vascular

infection

neoplasm

drugs

idiopathic/ inflammatory

congenital

autoimmune

trauma

endocrine/ metabolic

"Do not have to memorize"

pagets disease

a condition of unknown cause affecting about 3% of population over 40years, characterized by excessive and abnormal remodeling of bone

radiographic findings of Paget's disease

enlargement of an affected bone, increased opacity of involved bone, along with disorganized and coarsened trabecular pattern

Wi law for ordering x-rays

DPT degree or specialist certification

board approved residency or fellowship

formal training with ordering X-rays

What does Wi X ray ordering law require?

Therapist communication of the order to the patient's PCP or HCP

When is communication not required for X ray orders?

Patient does not have a PCP

Patient was not referred by another practitioner

Or if radiologist does not identify a significant finding

How are radiographic views named?

by beam entry and exit

ex: AP- entered anterior exit posterior

ex: PA - Chest/hand

plain film radiograph... Accuracy? Cost? Distortion type? What is it best for? Converts what to what?

accuracy to less than mm

cheapest (with exception of diagnostic US)

point source distortion

3D info turned into 2D

best for bone

What shows up as black on an X-ray? Type of residences?

least radiodense (air)

more radiolucent

What shows up as white on an X-ray? Type of residences?

most residence (bone)

more radiopaque

What is magnification of x- rays? Close vs far? Resolution impact?

structures that are closes to the beam source are enlarged and have less resolution

structures farther are less enlarged and more resolution

What are contrast enhanced studies? What do mediums do?

medium injected into body

improve visualization of areas with minimal inherent contrast

What is an arthrogram? Where can it be injected? What are limitations of this? What can it be combined with?

contrast media study of a joint and soft tissue

shows abnormalities of synovium articular cartilage, capsule and soft tissue

limitations- not multiplanar, invasive

can be combined with advanced imaging to get more info

What is a myelogram? What are some abnormal results?

contrast media of spinal cord maters and nerve roots

abnormal results: ruptured disc, spinal stenosis, nerve root injury, intravertebral tumor

What is a fluoroscopy? What are they used for? What is another term for it?

real time/ open shutter x ray

used for angiography, catheter placement, arthrography, myelography, facet joint injection

"Open-shutter" X-ray

What are the ABCs of reading radiographs?

Alignment, Bones, Cartilage, Soft tissue

What are the A's (alignment) for radiographs?

subluxation, dislocation, diastasis

What is subluxation?

A displacement of a bone in relation to apposing bone at the joint

results in partial loss on continuity of joint surfaces

What is dislocation

a displacement of a bone in relation to the apposing bones at the joint, resulting in A COMPLETE LOSS OF CONTINUITY OF THE JOINT SURFACES

What is diastasis?

A displacement of bone in relation to the apposing bone in a slightly movable or synathrodial joint

What are the 3 abnormalities that the "B" (bones) fall into?

1) abnormal contour

2) abnormal size and shape

3) abnormal opacity

-decreased opacity (lucency)

-increased opacity (sclerosis)

In normal bone what are osteoclasts? Osteoblasts?

They are in equilibrium

Osteoclasts: Bone removers

Osteoblasts: bone formers

What happens when osteoclasts are stimulated in normal bone? What does this cause for bone mass and opacity?

Osteoclasts have the capability to reabsorb bone 20x faster than osteoblasts lay it down

Causes net bone loss and decrease opacity (increased lucency)

What are other causes of decreased opacity?

Lucent line (fracture)

Focal lucency (tumor and infection/Osteomyelitis)

Diffuse lucency (drugs, endocrine/metabolic, tumor)

What is diffuse lucency? Most common metabolic disorder?

A global process

Osteoporosis

What are causes of increased opacity? (sclerosis)

bone impaction or rotation (fracture)

bone production fracture-> callus, tumor-> tumor bone, infection-> periosteal reaction, osteoarthritis-> subchondral sclerosis

What is a fracture callus? Why can't they be seen?

Callus's can only be seen once they have started to heal

What is cartilage? What are 3 things you can see with cartilage?

cant really see on plain radiograph

can infer how cartilage is doing by looking at joint space

1. Decreased joint space, most common, Infers arthritis (OA commonly followed by RA)

2. Increased joint space, acromegaly or joint effusion

3. Chondrocalcinosis

What is chondrocalcinosis?

most commonly due to calcium deposition in the joints (knee, wrist, pubic symphysis

What are examples of S? (soft tissue)

swelliing

- most common, usually not diagnostically helpful

gas

- pentrating injuries, following surgery, soft tissue infections infections due to gas-forming organisms

calcification (non specific)

- non-specific

mass (hematoma, absess, tumor)

- MRI more helpful imaging choice for most masses

When would we use an open mouth view? (AP, lateral)

When there is a basic C-spine injury? (cervical) (AP, lateral)

When would you use swimmers view?

Lower C-spine injury

When would you use a coned view image?

L-spine basic injury

What are each of the items labeled 1-9?

Slide 39 in first powerpoint

What is an ultrasound?

imaging using sound

diagnostic and therapeutic

considered cheapest and safest imaging modality

rugged and portable

real time

Radiation free

What are the uses of ultrasound?

lesions to muscles, tendons and ligaments

detection of cyst

measure blood flow

can be dynamic

What are some limitations of ultrasound?

operator dependent

does not penetrate bone

does not cross air

does not work well in obese

What is nuclear imaging?

tracer is absorbed by specific tissues in varying amounts based on metabolic activity within that tissue

pathologies can be identified by variation in uptake

Gamma rays are emitted from body

What are the SPECT and PET imaging tools and info do they provide?

neuclear medicine imaging techniques which provide metabolic and functional info when combined with CT and MRI

What is PET positron emission tomography? Characteristics?

expensive

uses position emitting radiosisotope

better contrast and spatial resolution

What is SPECT single photon emission computed tomography? Characteristics?

lower cost

uses gamma emitting radiosotope

What is a Bone Scan?

early indicator of increased bone activity

abnormal conditions show increased uptake of tracer (technetium

What do you want to do first when imaging bone? Which X-ray modality?

Plain film radiographs

CT scan would be second

What are some principles of CT?

merges x rays and computer technology

provides detailed x sectional images

same imaging principles as radiology

reflect radiodensity

Some software can reformat into 3D images

Free from superimposition

What does "free from superimposition" mean in a CT scan?

Radiodense structures appear white

Less dense structures appear dark

Air < Fat < Water < bone

It is opposite from an MR image

What are the principles of an MRI?

uses magnetic field and radiofrequency signals

What is an MRI best for seeing? (6)

Bone marrow changes (tumor, AV)

Soft tissue

Disk herniations

Nerve root impingement

Neoplasms

Bone METS (more sensitive than bone scan, as those are used for screening)

CT vs MRI

usually MRI except osteomyelitis and stress fractures

CT= complicated fractures

What is the difference between a T1 and T2 MRI?

- T1 (anatomical)- fast to acquire, excellent structural detail, fluid is dark

- T2 (pathological)- slower to acquire, fluid appears bright

What is a CT scan best for? (5)

Loose bodies in a joint

Subtle or complex fractures

Degenerative changes

Serious trauma

Spinal stenosis

If someone has osteomyelitis, which diagnostic imaging test should be used? MRI, CT, or NM?

1a. NM, 1b. MRI

If someone has a complicated fracture, which imaging test should be used?

A CT scan

If someone has suspected stress or an occult fracture which diagnostic imaging test should be used? (MRI, CT, or NM)

NM

Which two modalities cost the most to use? (MRI, CT, Ultrasound, PET, SPECT)

MRI

PET

what region of the spine is the most mobile and why? (examples of what it can be used for?)

The cervical spine is the most mobile

Needed for vision and balance, allows for rapid head motions

why does cervical spine need stability

The cervical spines uses the "Sense organs"

needs protection for the vital "tubes"

In the upper cervical spine; what is the "craniovertebral complex" made up of?

occiput, atlas, axis

OA and AA joints

What are C7, T1, T2?

transitional segments

what is the lower cervical spine made up of? what motions occur here?

C3-7

motion occurs in all planes (primarily the sagittal)

What is a transitional vertebral segment? what vertebrae make up the transitional segments?

The vertebrae has characteristics of both regions

C7, T1, T2

how is epidemiology data useful in patient care

needed for clinical reasoning and likelihood ratios (ex: most patients with neck pain will have a musculoskeletal neck disorder)

what is the difference between incidence and prevalence?

Incidence: # of new cases in a time period / population at risk

Prevalence = # of existing cases at point in time / population at risk

Lots of new cases but ending in death over a short duration would be an example of what kind of incidence and prevalence

this would e an example of high incidence but low prevalence (high incidence due to the large number of deaths; low prevalence due to the short duration)

high prevalence example: OA

low prevalence example: common cold

On a global scale, what is the ranking of neck pain as a global disability and overall burden disability (two rankings)

4th greatest global disability

21stgreatest of overall disability burden

what is the ranking in the US for neck pain as the most common MS disorder associated with injury and disability claims

Neck pain is 2nd only to LBP as the most common MSK disorder

who is at the highest risk for neck pain? (gender, age, cultures)

greater in women

increases with age (peaking in 35-49)

cultural risk- head carrying cultures (Africa)

what happens after someone experiences neck pain (turns into? what kind of pain? how long will it last?)

44% will go to develop chronic conditions

32% moderate residual pain

50-85% will report neck pain 1-5years later

what are some common risk factors for cervical spine neck pain? (Gender? age? job type? physical activity?)

female

45-59

heavy labor

office/ computer jobs

health care

unemployed

sedentary work

repetitive work

smoking

previous neck pain

depression

job strain

low co worker social support

what is mechanical neck pain? what is the most common cause of mechanical neck pain?

Neck pain that behave mechanically (pain is influenced by movement, position); serious pathology (fracture, disease) have been ruled out

this is a type of musculoskeletal cause

What are some common causes of musculoskeletal neck pain? are PT's better at figuring out these issues?

soft tissue injury (ligament, muscle, capsule)

degenerative changes in zygapophyseal joint

joint pain

fracture

dislocation

PT's should be better at treating this one compared to non-musculoskeletal causes

non msk causes of neck pain

infection

tumor

cardiac

endocrine

GI

neurological

pulmonary

systemic disease

Do most patients with neck pain have a specific cause? what is the is called?

Specific PATHOANATOMIC cause is not known in musculoskeletal causes

what are pain characteristics associated with nonmusculoskeletal symptoms (location, chronology)

location: deep, non specific

chronology: constant, unrelated to movement, night

what are red flag symptoms of neck pain associated with nonmusculoskeletal symptoms

insidious onset with no mechanical association

symptoms unchanged by movement or position

not proportionate to injury

unexplained swelling, paresthesia, weakness, tone changes

unintended weight loss

visual changes

growing mass

changes in skin or nails

pain associated with exertion/ exercise

bowel/ bladder changes

dyspnea, shortness of breath or dysphagia

changes in skin or nail condition

constitutional symptoms: fatigue, fever, dizziness/fainting

What are the signs and symptoms of tracheobronchial conditions

Signs: inflammation, viral and bacterial infection, tumor

symptoms: referred neck pain, dyspnea, dysphagia, persistent cough, fever/chills, hemoptysis

what are the types of tumors associated with the neck? how common are they? what are some symptoms

-Bone: overall uncommon; more common in young adults

-spinal cord: less common than intracranial CNS tumor

-esophageal, thyroid

Symptoms: neck pain, sore throat, dysphagia, growing mass, UMN signs (if spinal cord is involved)

What is a pancoast tumor? what are some common symptoms

Pancoast tumor: Lung cancer in the upper lobe that invades the lower brachial plexus

symptoms:

-extrapulmonary: pain in shoulder and scapula and referred pain down the arm

-pulmonary (uncommon): cough, chest pain

What is Honer's syndrome?

if the tumor invades the sympathetic chain

what is osteomyelitis in the neck and common symptoms?

Osteomyelitis: bone inflammation that is secondary to an acute or chronic infection

Symptoms: neck pain, stiffness, fever

what is discitis

disc inflammation that can be infectious, disc narrowing

causes neck pain, stiffness, and fever

what are some cardiovascular conditions that refer pain to the neck?

acute myocardial infarction (neck and jaw)

acute coronary insufficiency

carotodynia (painful carotid artery)

what are some GI conditions that refer pain to the neck?

esophageal infection, tumor, varices

symptoms: dysphasia ant neck pain

what are some other conditions that can refer pain to the neck?

lymes

RA

ankylosing spondylitis

fibromyalgia

klippel- fiel

thyroid

-hyper/hypo-thyroidism

what is klippel- fiel syndrome?

congenital fusion of cervical vertebrae

Occam's Razor (Law of Parsimony)

the simplest solution tends to be the simples one

what is the atlantoaxial joint / what does it pivot around?

bony ring pivoting around dens

What are the 5 ligaments that support the AA joint?

alar

cruciform (includes the transverse ligament which hold the dens to the arch)

accessory

apical

anterior atlanto- dental ligament

anterior atlanto- dens interval instability occurs after how many mm's? (AADI)

if > 3.5mm, instability occurs

sings and symptoms of upper cervical instability (could involve deficits in?)

deficits of ligamentous/bony/muscular support causing...

C2 pain

bilateral UE/ LE paresthesia

clumsiness

nystagmus

headaches

blurred visions

UMN (hyperreflexia, spasticity, abnormal gait, Clumsiness, Babinski)

what are some of the main causes of atlantoaxila instability?

congential bony malformation

down syndrome

inflammatory

trauma

chronic corticosteroid use

how does down's syndrome affect atlantoaxial instability?

causes AAI incidence, ligamentous laxity, special Olympics position statement

inflammatory causes of Atlantoaxial instability?

RA

psoriatic arthritis

anklyosing spondylitis

osteomyelitis

Trauma causes of atlantoaxial instability?

MVA: head striking windshield

football: spearing

What is radiculopathy?

nerve root impingement

causes sensory and motor changes

how do nerve roots exit at a level?

nerve roots exit above the named level

two common sequences of impingement of the nerve?

radiculopathy: nerve root and sensory/motor changes

myelopathy: spinal cord; UMN signs

during the standard orthopedic patient interview (history portion) what is included

demographic

employment

condition

medical care

functional status

social history

current health status

personal health history

family health history

what is the self-report instrument tool used for the neck?

Neck disability index (NDI)