Strain
muscle-tendon injury
Sprain
ligament injury
Compression pain from?
nerve root leaving spine pinched or irritated
Radiculopathy is?
nerve root dysfxn
signs/sxs in dermatomal distribution
Sciatica is?
Radiculopathy in root (L4, L5, S1)
sxs along post or lateral lower leg
(U) to ankle/foot
Myelopathy presentation
(Upper motor neuron) Hyperactive reflexes Spasticity Weakness Atrophy
Radiculopathy presentation
(Lower motor neuron) Hypoactive reflexes Flaccidity Weakness Atrophy
What two systems should you always check together?
musculoskeletal and neurological
Secondary Gain is?
Pt looking for a benefit from their pain:
- drug seeking
- disability (work comp, etc)
- lawsuit
Diagnostic studies
CT: best for bony detail
MRI: best for soft tissue, neural
Bone Scan: best for infection, metabolic disease
Neurophys studies
EMG: for root vs peripheral vs plexus nerves
Nerve Conduction: for axon vs myelin
Findings on spine films
- misalignment
- narrow disk space
- osteophytes (esp on intervert foramina)
Cervical Strain/Sprain etiology
rapid deceleration w/ hyperextension then flexion of neck
Cervical Strain/Sprain presentation
(U) presents 2-24 hrs post trauma
- gradual onset stiff/sore
- (P) tension-type HA
- (P) shoulder pain
Lumbar Strain/Sprain etiology
secondary to event (e.g. twist, lift)
Lumbar Strain/Sprain presentation
- acute onset post event
- (U) worse w/ activity
- (U) radiates to butt
Physical Exam for Strain
- may be normal initially
- (P) ↓ ROM 2° to pain
- (P) tender to palpation
- normal neuro exam
Diagnostics for Strain
X-ray:
Cervical
- AP/Lat/Odontoid
- must see C7
- flex/ext if c-spine cleared
Lumbar
-AP/Lat
CT/MRI: rarely helpful
Strain tx
48 hr Theraputic Trial (conservative):
limited activiy
ice/heat
NSAIDS round the clock
Clinic Course for Strain
1/2 resoluve <4wks
5-10% become chronic
Cervical Spondylosis etiology
combo of disk degener/hypertrophy of lig flavum and facets
2nd most common cause neck pain
Cervical Spondylosis presentation
- (P) single level involvement w/ unilat radicular sxs
- (P) multi-level w/ bilat sxs
- (P) nyelopathy if disk herniation compresses cord
Cervical Spondylosis physical exam (check for)
- tenderness, spasm
- radicular sxs (low motor neuro findings)
- cord comress (up motor)
- uni or bilateral
- levels affects (U) C4-7
Cervical Spondylosis tests
MRI = extensive disease, bulging disks, lig hypertrophy
Herniated Lumbar Disk Disease findings
- disks proturde, extrude or free fragments
- herniation (U) L4-5 or L5-S1
- herniation (U) posterolateral (longitudinal lig is weakest)
Herniated Lumbar Disk Disease presentation
(from repetitive movements)
- SCIATICA sxs
- (P) trunk shift
- (P) neuro defects following dermatome
Herniated Lumbar Disk Disease tests
x-ray = (P) ↓ disk space, osteophytes MRI = will be diagnostic
Cervical/Lumbar Spondylosis tx
Theraputic Trial (conservative):
- Short rest
- NSAIDS
- cyclobenzaprine (m relax)
- heat/cold
Urgent referral for neuro defects
Cauda Equina Synd etiology
NEURO EMERGENCY
massive midline herniation
(P) also from trauma or metastatic dx
Cauda Equina Synd presentation
- acute LBP w/ sciatica
- ANY ∆ in bowel/bladder
- “saddle” anesthesia: butt, post/sup thighs, perinea
- global or progressive bilat LE mm weakness
Cauda Equina Synd tests
MRI
Cauda Equina Synd tx
herniation or trauma = urgent surgical decompression
metastatic dx = urgent oncology for radiation
Spondylolysis etiology/tx
defect in pars interarticularis from repeat hyperextension (e.g. athletes)
(U) kids/adoles
tx w/ NSAIDS and rest if LBP
Spondylolisthesis etiology
ant displacement of one vertebra onto another
(U) w/ degen disk dxs
(U) L4-5, L5-S1
Spondylolisthesis presentation
LBP ↑ w/ movement, 2º to instability
If root compression, herniated disk sxs
Spondylolisthesis tests
X-ray including ext/flexion
Spondylolisthesis tx
Depends on grade of displacement:
50% displ: spinal fusion
Neuro impairment = refer ortho/neuro
Lumbar Spinal Stenosis etiology
- Acquired or congenital
- Degenerative disk dx w/ hypertrophy of ligamentum flavum
- Narrows neural foramen -> compresses nerve or cord
- MOST COMMON cause of neuro leg pain in old people
Lumbar Spinal Stenosis presentation
Neurogenic claudication:
progressive LBP w/ bilat leg pain
- pain ↑ w/ stand, walk
- RELIEF by LEANING FORWARD
Lumbar Spinal Stenosis imaging findings
- ↓ height of intervert discs
- facet hypertrophy
- lig flavum hypertrophy
- narrow intervert foramina
Lumbar Spinal Stenosis tx
Conservative:
NSAIDS, PT
(P) steroid inject or surgery
Spinal Tumors etiology
Primary tumors rare: multiple myeloma
Metastatic common: most terminal CA include spine tumors
Spinal Tumors presentation
NIGHT PAIN, dull, progressive
Osteomyelitis etiology
infection assoc w/
invasive procedures, DM, ↓ immun
Osteomyelitis presentation
back pain, malaise, fever
sepsis, wound drainage
↑ ESR
Osteomyelitis tx
abx
surg drainage
Red Flag/Alarm sxs with neck/back pain
- old, immun suppressed, IV drug user
- hx of CA
- pain > 1 mo
- fever
- UTI
- worse when supine
- unexplained weight loss
Red Flag for Spinal Frx
- hx significant trauma
- long use of corticosteroids
- Age >70