T&L spine

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low back pain

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1

low back pain

common, affects 60-70% of the adult population -most resolve within 30 days, some chronic lasting over 90 days -some experience flares thru-out life -pain in the lumbar paraspinal muscles that can radiate to the buttocks, hips, proximal thighs -possible muscle spasms -unilateral radicular pain in a dermatome distribution

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2

causes of lower back pain

underlying cause normally not found, but can be -mechanical -infections such as spondylodiskitis, neoplasms, bone diseases, fibromyalgia

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3

workup for low back pain

full PE: posture, gait, palpation, ROM, strength, sensation, DTRs, special tests such as straight leg raises, FABER, Waddell, look for red flags

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4

myotome

group of muscles that a single spinal nerve root innervates

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5

elbow flexion

C5 myotome

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6

wrist extension

C6 myotome

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7

elbow extension

C7 myotome

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8

finger flexion

C8 myotome

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9

finger abduction

T1 myotome

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10

hip flexion

L2 myotome

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11

knee extension

L3 myotome

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12

ankle dorsiflexion

L4 myotome

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13

great toe extension

L5 myotome

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14

plantar flexion

S1 myotome

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15

C5, C6

spinal roots for biceps reflex

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16

C6

spinal root for brachioradialis reflex

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17

C7

spinal root for triceps reflex

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18

L4

spinal root for patellar reflex

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19

S1

spinal root for achilles tendon reflex

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20

back pain red flags

be sure to be attentive to:
-onset
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21

lumbar strain

injury to the paravertebral spinal muscles, strain of the lower lats -ligamentous injury that can affect the facet joints, annulus fibrosis, spinal longitudinal ligament -diffuse pain -often with history of lifting or twisting injury -can radiate to the buttocks, hips, proximal thighs

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22

lumbar strain presentation

pain that is hard to pinpoint on palpation, with associated spasms and trigger points -pt may have difficultly standing erect, changes positions frequently for comfort -referred pain in the buttocks or thighs

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23

bed rest, NSAIDs, muscle relaxants, heat/ice, stretching, PT, massage

treatment for lumbar strain

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24

superficial or nonanatomic tenderness

Waddell signs of malignering for tenderness

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25

axial loading test

Waddell's sign: light vertical loading over the pts spine in standing position causes lumbar pain

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26

acetabular rotation

Waddell's sign: pain is reported when the pelvis and shoulders are passively rotated in the same plane as the pt is standing -positive test if pain within the first 30 degrees

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27

straight leg raise discrepancy

Waddell's sign: marked improvement of straight leg raising on distraction compared with formal testing

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28

double leg raise

Waddell's sign: organic response is greater with after both legs are raised than with single leg raising

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29

regional disturbances

Waddells sign: weakness, cogwheeling, giving way of many muscle groups that cannot be explained on neuro bases -sensory disturbances, overreaction to sensation

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30

chronic low back pain

pain lasting more than 3 months -usually pts are 30-60yo -recurrent and episodic pain caused by degenerative changes -radiate into the buttocks, worse with bending, twisting, lifting, stooping -stiffness, decreased ROM -back and leg fatigue -often relieved by lying down

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31

XR, MRI

imaging for chronic low back pain

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32

NSAIDs, muscle relaxants, heat/ice, PT, activity modification

treatment for chronic low back pain

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33

no need to image

Pt presents with low back pain without traumatic onset, no indications of serious underlying pathology. Do you image?

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34

lumbar spondylosis

degeneration of the lumbar spine, usually onsets >40yo -may be asymp or cause pain in various locations -may be due to degenerative disk disease, facet arthropathy, spondylolisthesis, stenosis

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35

intradiscal vacuum phenomenon

gas seen in the disks of the spine seen in degenerative changes

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36

spondylolisthesis

forward slip of one vertebra onto another -usually L5-S1 -most common cause of LBP in teens, due to spondylolisthesis after 40yo -can be congenital, degenerative, isthmic due to stress fractures, traumatic

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37

spondylolisthesis presentation

pt presents with LBP that radiates down into the buttocks or leg, possible leg weakness -pain with ROM, worse while standing and better with sitting -may have a palpable gap along the vertebra

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38

medical treatment

treatment for grade I and II spondylolisthesis (25-50%)

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39

surgery

treatment for grade III-V spondylolisthesis (>50%)

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40

XR for spondylolisthesis

AP/lateral, oblique shows "scotty dog view", flexion/extension images to eval for instability

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41

MRI or CT myelogram

imaging to detect canal stenosis in spondylolisthesis

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42

NSAIDs, PT

treatment for spondylolisthesis

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43

surgery

treatment spondylolisthesis if neurological compromise or failed conservative treatment

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44

lumbar stenosis

narrowing of the central spinal canal and/or neuroforamen with compression of the cauda equina and exiting nerve roots -usually due to bulging discs, osteophyte formation, thick and hypertrophic ligaments, facet arthropathy -pts >60yo L4-L5 most common, then L3/4, L2/3, L5/S1

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45

lumbar stenosis presentation

pt presents with slowly progressive LBP with leg pain/cramping/numbness/weakness -symptoms are worse standing and walking, relieved bending and sitting

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46

XR, MRI, CT myelogram

workup for lumbar stenosis

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47

NSAIDs, PT, epidural steroid injections

conservative treatment for lumbar stenosis

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48

laminectomy, foraminotomy, fusion surgery

treatment for lumbar stenosis if conservative fails

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49

lumbar disc herniation

weakening in the annulus leads to nucleus pulposis bulging out -most common at L5-S1, then L4-L5 -pain and numbness in a dermatomal distribution with possible weakness

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50

lumbar disc herniation presentation

pt presents with abrupt unilateral leg pain in a dermatomal distribution will often complain of leg pain over back pain -pain is worse sitting, better standing or walking

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51

PE for lumbar disc herniation

perform motor and sensory exam, DTRs, straight leg raise test for radiculopathy

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52

30-70 degrees

Pain in what range indicates radiculopathy in the straight leg raise test?

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53

MRI, CT myelogram

workup for lumbar disc herniation

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54

NSAIDs, Medrol (oral steroids), muscle relaxants, PT with traction, nerve root block, epidural steroid injections

treatment for lumbar disc herniation

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55

cauda equina syndrome

surgical emergency -L2-S5 nerve roots compressed, causing weakness or paralysis, impaired bladder/bowel control, loss of sexual function -due to a sudden decrease in the size of the lumbar canal and compression of the nerve roots

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56

lumbar disc herniation, epidural hematoma, epidural abscess, trauma

possible causes of cauda equina syndrome

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57

cauda equina syndrome presentation

pt presents with sudden onset bilateral leg pain and numbness, perineal numbness in saddle distribution -leg weakness and stumbling gait -loss of urinary and anal sphincter control

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58

PE for cauda equina syndrome

perform PE with DTRs, lower extremity sensation, motor strength, gait -test ability to rise from a chair, walking on the heels and toes -test perineal sensation and sphincter tone

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59

MRI, CT myelogram

workup for cauda equina syndrome

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60

emergency surgery to decompress nerve roots

treatment for cauda equina syndrome

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61

trauma, cancer, osteoporosis, chronic steroid use

causes of fractures in the lumbar spine

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62

compression fracture

usually due to axial loading, can be traumatic or idiopathic -common in older adults with osteoporosis -thoracolumbar junction most common -usually stable fractures

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63

compression fracture presentation

pt presents with thoracolumbar pain with movement, standing, or walking -worse with coughing, sneezing, straining -better when supine -percussion and palpation of suspected vertebrae is extremely painful -increased kyphosis or burst fracture development can impinge spinal cord

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64

wedge compression fracture

fracture that typically results from flexion forces, the anterior column is compressed while the middle column remains intact -usually causes no neuro deficits

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65

XR, MRI, myelogram

workup for compression fractures

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66

post menopausal females, females with predisposing medical conditions, aging males

What patient populations should be investigated further in terms of suspicion of malignant fractures?

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67

osteoporosis

radiography may be hard to detect with, but can see increased radiolucency and cortical thinning -invagination of the end plates into the weakened vertebral bodies in a "fish deformity"

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68

NSAIDs, acetaminophen, narcotics

treatment of acutely symptomatic compression fractures

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69

early mobilization, soft bracing, muscle relaxants, treat underlying osteoporosis

treatment of moderately severe compression fractures

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70

vertebroplasty

surgical repair of the vertebra, inject artificial cement into the vertebral bodies

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71

kyphoplasty

surgical repair of the vertebra that restores original vertebral height

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72

risks of vertebro/kyphoplasty

cement can escape the vertebral body and cause neuro impairment, increased risk of adjacent vertebral fracture

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73

6-10 weeks

How long does it take for compression fracture pain to resolve? -any longer suspect multiple myeloma or other underlying conditions

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74

chronic pain after vertebral fracture

can happen even after vertebral fractures are healed, due to abnormal strain on muscles, ligaments, tendons -facet-joint arthritis can occur

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75

back and core strengthening exercises, transcutaneous nerve stimulation, heat treatments

management of chronic pain following vertebral fracture

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76

transverse process fracture

fracture of the transverse process only, no lamina, pedicle, body or facet complex involvement -often associated with other injuries such as organ injury or pelvis fractures

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77

pain control

treatment for transverse process fracture

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78

flexion-distraction injury

flexion with axis of rotation between the anterior and posterior longitudinal ligaments -compression fracture of the anterior column, distraction failure in the middle/posterior columns -rupture of the posterior longitudinal ligament with instability

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79

chance fracture

due to a flexion-distraction mechanism -horizontal disruption of the spinous process, lamina, transverse process, pedicles and vertebral bodies -associated with wearing a seatbelt without the shoulder harness

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80

burst fracture

anterior and middle columns of the spine fail under axial compression force -posterior vertebral body cortex is disrupted, spinal cord at risk of injury from retropulsion of bone fragments into the spinal canal

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81

translational injury

failure of all three columns of the spine due to shearing forces -displacement of the spinal column in the transverse plane, compromise spinal canal and with neuro def -slice fractures, rotational fractures, pure dislocations

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82

trauma surgery and neurosurgery

management of major spinal column injuries

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83

CT of the spine, chest, abdomen, pelvis, MRI if any neuro def or concerns for ligamentous injury

imaging for major spinal column injuries

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84

bracing, surgical spinal stabilization

treatment for major spinal column injuries

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85

sacroiliitis

inflammation of one or both sacroiliac joints -due to trauma, infection, degenerative disease, pregnancy, spondyloarthopathies such as ankylosing spondylitis and reactive arthritis

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86

sacroiliitis presentation

pt presents with pain in the low back, buttocks, thigh that worsens with prolonged sitting or walking -tenderness on the SI joint in the back dimples +FABER test -erosion, calcifications, sclerosis in the SI joint

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MRI with contrast

imaging for sacroiliitis

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88

IV antibiotics, surgery if failure or abscess

treatment of sacroiilitis due to infection

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89

rest, activity modification, NSAIDs, corticosteroid injections

treatment of sacroiilitis due to trauma or overuse

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90

observation

treatment of sacroiilitis during pregnancy

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91

agressive PT, NSAIDs, TNF inhibitors, treat underlying cause

treatment of sacroiilitis due to a larger spondyloarthropathy

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92

scoliosis

the spine becomes abnormally rotated and curved due to congenital malformation, idiopathic, degenerative changes, neuromuscular probs such as cerebral palsy or muscular dystrophy -adolescent age, F progress faster than males, family history significant -worsen progressively as the child grows

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93

scoliosis presentation

pt presents with uneven shoulders, head not centered above the pelvis, raised hips, uneven waist -Cobb angle on XR > 10 degrees

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94

XR, CT, MRI if neuro symptoms

workup for scoliosis

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95

none needed

treatment for scoliosis with Cobb angle under 25 degrees

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96

brace

treatment for scoliosis with Cobb angle 25-45 degrees

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97

fusion surgery

treatment for scoliosis with Cobb angle over 45 degrees

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98

kyphosis

abnormal rounding of the upper back due to congenital changes, postural changes, Scheuermann's disease, degenerative changes

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99

age-related kyphosis

changes in the thoracic spine due to underlying osteoporosis and fractures, F>M

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100

Scheuermann's kyphosis

changes in the thoracic spine that develops in teens, M>F -multiple consecutive vertebrae are wedge-shaped

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