Cona Lecture Midterm Study Guide

Affected muscle in Upper Motor Neuron Lesion.

Increased

Affected muscle in Lower Motor Neuron Lesion

Decreased

Location of lesion of Upper Motor Neuron Lesion

Cortex, Internal capsule, Brainstem, Corticospinal tract (CNS)

Location of lesion of Lower Motor Neuron Lesion

Anterior horn cells, spinal roots, peripheral nerves, cranial nerve nuclei

Reflex findings of Upper Motor Neuron Lesion

Hyperreflexia

Reflex findings of Lower Motor Neuron Lesion

Hyporeflexia or areflexia

What is the location of the spinal cord?

Medulla to L1-L2

What are the spinal cord house (within)?

Upper Motor Neuron Tracts, Interneurons, and Lower Motor Neurons in the anterior horn

What is the other term for Cauda Equina?

Horse’s Tail

What are peripheal Nerve Bundles?

Collections of axons from multiple spinal levels organized into fascicles and surrounded by Endoneurium, Perineurium, and Epineurium.

What are examples of the Peripheal Nerves?

Sciatic, median, ulnar

What causes meningeal irritation?

When the protective layers around the brain and spinal cord become inflamed or irritatedW

What are the clinical indications of Meningeal Irritation?

Neck stiffness, photophobia, headache, positive kernig’s sign or brudzinski’s sign

Define lumbar central canal stenosis

The central spinal canal in the lumbar spine becomes narrowed leading to compression of the cauda equina nerve roots

What are the common demographics for central canal pathologies? (Lumbar)

60-years old or older, Male

What is the definition of tethered cord and common findings on visual inspection and clinical assessments?

A neurological disorder caused by abnormal attachmentf of the spinal cord. Limits movment and causes stretching and damage to the cord.

What are the common patient presentations for central canal pathologies? (lumbar)

Low back pain, Neurogenic claudication (Hallmark Symptom), Leg symptoms, Gait Changes

What are the common demographics for central canal pathologies? (cervical)

50-years old or older, A little more male then female

Common presentation and clinical findings for cauda equina syndrome and ED referral

A neurological emergency caused by compression of the cauda equina (nerve roots below L1-L2) typically from disc herniation, tumor, trauma, or spinal stenosis

What is saddle anesthesia? (Feels like sitting on a saddle)

Numbness in perineum, buttocks, and inner thighs. Common clinical presentation of cauda equina syndrome.

What are early signs of Cauda Equina?

Urinary Retention, patient will not notice that they are pissing themselves.

What is spondylosis?

Osteoarthritis of the spine

What is Spondylolysis?

Bone stress response or stress fracture of the pars interarticularis

What is Spondylolisthesis?

Vertebral body translates forward because of spondylolysis

What is Spondylitis?

Inflammatory arthritides including ankylosing spondylitis, psoriatic spondylitis, reactive spondylitis

What is Grade 1 of Spondylolisthesis?

Dysplastic (Type 1)

What is Grade 2 of Spondylolisthesis?

Isthmic (Type 2)

What is Grade 3 of Spondylolisthesis?

Degenerative (Type 3)

What is Grade 4 of Spondylolisthesis?

Traumatic (Type 4)

What is Grade 5 of Spondylolisthesis?

Pathological (Type 5)

Degenerative (Type 3)

MC. MC at L4/L5 due to age related density alterations (Post-menopause)

Isthmic (Type 2)

Fatigue fracture seen in young athletes with repetitive extension

What is the definition of Creep?

Gradual deformation of the disc when under a constant load

Is Creep routinely pathological?

No, if temporary loss of disk height that is asymptomatic or seen on imaging without consistent signs/symptoms, don’t pathologize the image findings.

What is Disc Derangement?

An umbrella term to define pathology to the disc

What is Disc Degeneration?

Common degradation of disc material, NOT necessarily due to the consequences of aging

What can cause a Disc Derangement/Degeneration to initiate?

Initiated by mechanical and/or nutritional/hydration insult to the disc

What can cause Disc Derangement/Degeneration to occur?

Again, apoptosis, collagen abnormalities, vascular changes, abnormal disc loading, abnormal proteoglycans, loss of disc nutrition/hydration

What are the results of disc derangementdegeneration?

Loss of disc high —→ associated biochanical changes when loaded

What can Disc Derangment cause to speed up?

More rapid creep resulting in more vulnerable to further damage —→ less ability to recover —→ increased susceptibility to re-injury

How to heal disc derangement/degeneration?

Healing rate increases if we are properly hydrated

What is discogenic pain?

Mechanical insult to the disc causing chemical or inflammatory response that closely inersect with peripheral and central nerve system. PNS and CNS involvement can cause nerve sensitization and ingrowth

Intervertebral disk derangements - Bulge

• Mild displacement of annular fibers typically due to slight nuclear disruption

• Involves at least 50% of the circumference of the disc, but may involve up to 100%

• Posterior longitudinal ligament (PLL) is intact

  • May be caused by disc degeneration, response to abnormal or angular loading or even normal events

Intervertebral disc derangements - bulge - experience

• pain increases with flexion

• flexion is limited

• no radicular pain

• somatic/referred pain is possible

• dural tension and dejerine’s triad is absent

• neuro exam is negative

• x-rays are negative

• probably asymptomatic

Intervertebral disk derangements - protrusion

• A focal outcropping of the annulus material

• Annulus fibers are thinner and can have some tearing

• Nucleus moves through the “tearing” typically in a posterior direction

  • posterior longitudinal ligament is intact

Intervertebral disc derangements - protrusion - experience

• Pain increased with flexion

• All ROM limited to some degree

• Somatic and/or radicular pain

• Antalgia

• Probable (+) dural tension signs & dejerine’s triad presence

• Neuro exam may be normal or be deficit

• X-ray: decreased disc angle or decreased lordosis or decreased lumbosacral angle

Intervetebral disc derangements - extrusion

• Rupture of the annular fibers

• Nuclear material emerges through the annulus fibers

• Nucleus pulposus is confined by the Posterior Longitudinal ligament

Intervetebral disc derangements - extrusion - experience

• Pain increases with flexion

• Radicular and somatic referred pain

• antalgia

• (+) Dural tension signs

• Hard neurological signs (abnormal)

• MRI evident

• X-ray same as protrusion

Intervertebral disc derangements - sequestration

• Posterior Longitudinal ligament disrupted

• Nucleus protruddeds into the epidural space

• displaced disc tissue is expelled from disc and is no longer attached

Intervertebral disc derangements - sequestration - experience

• Back pain history

• Changes to predominatly leg pain

• Early dural tension signs that may have disappeared

• Hard neurological signs present

• Dejerines triad absent

• unrelenting parasthesia/pain

• MRI

• Posterior migration of the free fragment can result in cauda equina syndrome and immediate E.D. referral

What type of patients is Meralgia Paresthetica present in?

Commonly seen in patients who are obese, pregnant, trauma, diabetes, certain medications or professions that require tight/heavy equipment held around waist (tool belt, police office, etc)

Facet Pathology

• History

• No neurological findings

• pain with extension/loaded extension

  • pain in sclerotogenous pattern

Disc Pathology

• History

• (+) Valsalva

• Pain with spine axial loading

• Potential neurological findings associatedwith femaminal stenosis due to disc herniation

• P,N,T in dermatomal pattern

• Pain in sclerotogenous pattern

  • Imaging

Neurogenic Claudication

• compression on spinal cord and/or nerve roots

• NERVOUS TISSUE

  • Unilateral (IVF STENOSIS) or bilateral (central stenosis)

Vasculogenic claudication

• compression of arteries of the legs

• BLOOD VESSELS

• MC cause is atherosclerosis

  • AKA: peripheral vascular disease, peripheral artery disease

Difference between neurogenic and vascular during a physical exam?

Neurogenic, relief by opening central canal or foramen by flexing forward. Vascular, fast relief with resting legs resulting in decreased blood flow demand to LE

Tethered Cord Syndrome

Condition of the spinal cord attaching to the lower spine

Potention dimples, hair tufts, hermangiomas, lipoma

Another way of saying impingement or pinched nerve?

Foraminal stenosis

What is foraminal stenosis caused by?

• disc material due to disc derangment

• Osteophyte due to osteoarthritis

• Decreased disc heigh minimizing foraminal space

• Spondylolisthesis

• Spinal instability

  • Any trauma causing excessive movement of the spine resulting in minimizing foraminal space

Lumbar radiculopathy

Refers to any disease that affects the spinal nerve root

Lumbar radiculopathy presentation

low back pain with pain, numbness, and/or tingling radiating down a unilateral leg

Sciatic neuropathy presentation

-Pain, tingling or numbness in buttock and posterior thigh area

-Present neurological findings for a LMNL

-If the patient also presents with back pain, it is not piriformis syndrome

Sciatic Neuropathy Causes

• Trauma, tumor near bundle, poorly performed injections, surgical complications, prologned significant pressure on nerve.

• Piriformis syndrome - sciatic bundle piercing through piriformis muscle causing an anatomical variance

• Effeccts 0.3% - 0.6% of Low Back Pain patients

• MRI or DU needed for correct diagnosis

Femoral Nerve Pathologies

Arises from L2-L4 spinal nerves and travels down the front of the thigh

• Relatively uncommon (0.1% - 2.4% prevalence

Femoral Nerve Presentation

Pain, numbess or tinglinng in thigh or inner thigh, weakness of quadriceps

What is the annulus nuclear complex degeneration progression?

1. Dysfunction: Micro-Tearing

2. Instability: Internal disruption and resorption

3. Restabilization: osteophyte and traction spurs —→ increased risk for foraminal and central stenosis

Dejerine’s Triad Sign

Patient is asked if coughing, sneezing and/or bearing down (valsalva) increased their symptoms

Dejerine’s Triad Sign Rationale

Increased intrathecal pressure created by any of these actions resulting in pain along the spine and/or unilateral or bilateral radicular symptoms can indicate a space occupying lesion

Tripod sign (AMOS Sign)

Patient is sseated with knees bent. During the exam the knees are passively or actively extended resulting in the pt leaning back or extending spine to reduce symptoms

Tripod Sign (AMOS Sign) Rationale

1. If the hamstring muscles are tight, the patient extends the trunk to relieve tension on the hamstring muscle.

2. If there is a nerve root pathology, the patient extends the trunk to relieve nerve tension

Minor’s sign

Patient goes from sitting to standing position and leans towards unaffect side, keeping affect leg flexed

Minor’s sign rationale

Patient with lumbar radiculopathy will maintain a flexed leg to decrease nerve tension on the lumbar nerve roots

Antalgic lean Sign

Patient leaning a certain direction when ambulating or in a seating or standing position

Antalgic lean sign rationale

Self-protective position to decrease pain and symptoms. Lateral disc derangement: patient may assume a flexed posture

Neri sign (neri bowstring)

When patient bends forwardd at the waist, they flex the knee on affect side to reduce,allevviate pain or radicular symptoms

Neri sign (neri bowstring) rationale

Forward flexion of lumbar spine creates neural tension. A flexed knee can slack the nerve/nerve roots to alleviate pain or radicular symptomms for a patient with lumbar radiculopathy

The four pathologies associated with facets:

Facet Joint Irritation (MC)

• two articular surfaces are compressed or shear against each other

• typically seen in lumbar extension and hyperextension MOI

• Can have flexion/extension pain or diminished pain in flexion

The four pathologies associated with facets:

Facet Joint Capsulitis

• Capsule surrounding the two articular surface is stretched

• typically seen in lumbar flexion MOI

• Can have flexion or extension pain, diminished pain in extension

The four pathologies associated with facets:

Facet Arthropathy

Spondylosis or osteoarthritic changes in the spine

The four pathologies associated with facets:

Facet imbrication

superior and inferior facets overlap excessively (like roof shingles)

Facet (z-joint) pathologies presentation:

• localized low back pain often accompanied with “achy” or “sharp” sclerotogenous referred pain into buttock that can travel into the foot

• Sudden onset due to misjudged movement causing “catching” or cramping sensation

• Insidious onset associated with chronic LBP

• Lumbar spine stiffness after laying down to sleep

• Postural lumbar hyperlordosis

Lumbar Myelopathy ends where?

L2/L3

Why does lumbar myelopathy end at its level?

That is where the central spinal cord ends in fully developed adults. Therefore, every symptom below this level is considered a radiculopathy because the Cauda Equina (otherwise nerve roots) begins.

What is lumbar foraminal stenosis caused by?

Extension of the lumbar spine, disc derangement/herniation, degenerative changes, spondylothesis, Paget’s disease (thickening of bone) acute injury, possible tumor growth, and maybe previous spinal injury.

Examples that do not cause lumbar stenosis:

Muscle strain, sciatic neuropathy, an isolated herniated disc (one pressing on the nerve root not without canal narrowing), peripheral neuropahy, inflammatory conditions like ankylosing spondylitis, and hip osteoarthritis

Patient presentation and clinical findings for lumbar radiculopathy

Sharp shooting peripheral pain (referral pain), tingling sensations, loss of sensation (anesthesia, parasthesia, hypoesthesia), weakening of muscle supplied by nerve levels and/or changes in reflexes (DTRs/Pathological reflexes…. remember these are monosynaptic…. meaning at one levek and on level only)

Body positions affecting discs

Depends on the movement and segments affected by the movement. Cervical and lumbar disc sit further up front on the vertebral body. Whereas, thoracic discs sit more middle/posterior. Using this information we can see how the spine “squishes” the disc during movement

Presentation and clinical findings for muscle strains

Onset of localized pain, tenderness, swelling or bruising, weakness or difficulty using muscle, and worsening pain during a stretching or contracting exercise.

Presentation and clinical findings for ligament strains

Acute joint pain, swelling aroundd joint or attachment site, bruising, joint instability, and pain with movement, especially that which stresses the ligament.

Muscle strain - Grade 0

DOMS (muscle soreness post exercise)

Muscle strain - Grade 1

Micro-tears. Pain and tenderness during or after activity. Strength and movement usually maintained

Muscle strain - Grade 2

Partial tear. Pain during activity preventing the ability to continue. Evident weakness, reduced ROM, potential bruising. May take 24hrs for symptoms to present.

Muscle strain - Grade 3

Partial tear. Sudden pain. Possible fall to floor. Evident weakness, reduced ROM, potential brusing.

Muscle strain - Grade 4

Full thickness/complete tear of muscle or tendon. Sudden and significant pain and immediate limitation to activity. A palpable gap and significant bruising. May have less pain on contraction compared to Grade 3.

Ligament strain - Grade 1

Descriptor: Low grade stretch injury (potential microtrauma)

Physical Exam Findings: Minimal tenderness and swelling

Treatment: Weight bearing as tolerated, active and passive care

Ligament strain - Grade 2

Descriptor: Partial tear, less than 50% is low grade, greater than 50-99% is high grade

Physical Exam Findings: Moderate tenderness and swelling, decreased ROM, possible instability of joint

Treatment: Immobilize with air splint, active and passive care

Ligament sprain - Grade 3

Descriptor: Complete tear, high grade injury

Physical Exam Findings: significant swelling and tenderness, joint instability

Treatment: Immobilization, surgical consult, active and passive care

Other pathologies that present as low back pain

• Prostate Hypertrophy/Cancer

• Metastatic Tumors

• Polynephritis

• Nephrolithiasis

• Pre-menstrual cramping

• Pelvic inflammatory disorder

• Endometriosis

• STIs

• Abdominal Aortic Aneurysm

• OSteomyelitis

• GI disorders

• Ret