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NYCC TCH 6705 Loia

NYCC Loia Exam 2 Evi. Based Clin Case Mgmt Sp2012

QuestionAnswer
#1 reason patients seek chiro care low back pain *2nd only to upper respiratory problems as a reason to see an MD
Obesity, age, gender, socioeconomics, disc degeneration, slippage (spondylolisthesis), herniation, muscle sprain/strain Factors correlated positively with BACK and NECK PAIN
3 CONGENITAL etiologic factors in LBP: 1. FACET TROPISM 2. TRANSITIONAL VERTEBRAE 3. SPINA BIFIDA OCCULTA
developmental asymmetry of the facet orientation or facing FACET TROPISM
TWO types of TRANSITIONAL vertebrae (congenital) SACRALIZATION & LUMBARIZATION ****DO NOT USE THESE TERMS.
The congenital cause of low back pain wherein the lamina do not fuse. SPINA BIFIDA OCCULTA
Where do thoracic spine compression fractures occur? lower thoracic
How many types of transitional lumbosacral segments? 4 (types I, II, III, IV)
Which type of LS transitional segment is most clinically significant? type II (unilateral)
Why is there no predisposition to herniation in type I LSTS? because there is no fusion and no articulation, only spatulation of TP's
Type II LSTS is most clinically significant because? there may be disc herniation AT SAME LEVEL and ABOVE, also painful
A transitional vertebra may reduce movement in the ___ motion segment. INFERIOR
When a transitional segment exists, why hypermobility above and below? Each of the other lumbar discs has to divide up and shoulder the weight of the disc who is out of the game.
Type II on one side, type III on the other Type IV – diarthrodal on one side, fused on the other
Clasp-knife syndrome found in Congenital spina bifida occulta
Spina bifida is exacerbated in lumbar extension
A prolapsed disc contributes to chemical irritation causing LBP by releasing? Nitric oxide
Damaged nerves release?/ Prostaglandins Prostaglandins
TNF is released by? disc herniation – annular tears – facet damage
3 examples of nerve root or meningeal tumors: Neurinoma, Hemangioma, Meningioma
Neurinoma consist only of Schwann cells, outside the nerve, but the tumor may have mass effect on peripheral nerve
4 examples of tumors involving VERTEBRAE Osteoid osteoma...Paget's disease...Osteoblastoma...Giant Cell tumor
ABC not actually a tumor. Usually in posterior lumbar spine. Women in late teens or 20's
GCT Aggressive. Sacrum and anterior spine. Women 30-40
Hemangioma benign. Thoracic and lumbar spine. Women 30-40.
Osteoid Osteoma common. Males 20-40. Posterior lumbar. Sometimes cause deformity.
Osteoblastoma Larger than O.O. & more aggressive. Males 20-30. Posterior lumbar.
Malignant tumors cause? NON-MECHANICAL back pain that is CONSTANT and NOT improved by rest or lying down.
example of primary bone tumor multiple myeloma, chordoma, osteosarcoma, chondrosarcoma, plasmacytoma
3 types of malignant tumors of the spine 1. Primary bone (multiple myeloma) 2. Primary neural 3. Secondary (mets)
Examples of SECONDARY malignant tumors of spine METS from breast, prostate, kidney, lung, thyroid, lymphoma, melanoma
Chordoma rare, slow. Male 50-70. Sacrum.
Osteosarcoma rare, highly malignant, easily spread. YOUNG males
Chondrosarcoma slow, thoracic, lumbar, sacrum. Males over 40. Poor prognosis.
Plasmocytoma ROUND CELL tumors. Single or multiple. Thoracic or lumbar. Males over 50.
Multiple myeloma ROUND CELL tumors – most common type of bone cancer in adults. 50-80 yo. Responds well to chemo.
None of the definitions for tumor types will be on the test but they will be on boards part II so study!
Two types of lumbar strain Acute & Chronic
Two types of fractures in lumbar Fx of vertebral body (compression fx) & Fx of transverse process
A so-called subluxated facet joint is _________ syndrome. facet syndrome
Two types of spondylos which may be congenital SpondyloLYSIS and SpondyloLISTHESIS (break and movement, respectively)
Name a heavy metal that could cause poisoning and subsequent LBP radium
Two types of metabolic dz involved with LBP osteoporosis and osteomalacia
Inflammatory arthritides that may cause LBP Rheumatoid arthritis, Ankylosing spondylitis, Myositis, Reiter's syndrome
Degenerative disorders that may cause LBP SpondyLOSIS, Osteoarthritis, Herniated disc or Nucleus pulposis, Spinal STENOSIS, Nerve root entrapment, Cauda equina syndrome
Infections which may cause LBP Acute (pyogenic), Chronic (TB, osteomyelitis, fungal, shingles), GI disorders (penetrating peptic ulcer referral pattern)
Circulatory disorders which may contribute to LBP AAA
Examples of Intrinsic causes of LBP (mechanical) Poor muscle tone, chronic postural strain, myofascial pain, unstable vertebrae
Examples of EXTRINSIC causes of mechanical LBP Uterine fibroids, pelvic tumors or infections, hip dz, prostate dz, SI jt infection or sprain, Untreated lumbar scoliosis, retroperitoneal process
Psychiatric problems that may cause LBP hysteria, malingerer, anxiety, depression, chronic pain
Fibromyalgia and myofascial pain are causes of LPB
What type of surgery causes LBP FAILED back surgery syndrome
Pt has antalgic, guarded posture and all orthopedic tests are POSITIVE for increasing LBP Lumbar SPRAIN-STRAIN with capsular inflammation; uncomplicated. 1st incidence. Any sudden movement, even deep inhalation, causes pain.
For chiro mgmt of lumbar sprain-strain, adjust into antalgic if not pathology and muscles will let you
GOALS of chiro tx for ACUTE lumbar sp-st presentation DECREASE pain and spasm, INCREASE mobility, STRENGTH and condition eventually
Although you may tx ACUTE lumbar sp-st daily at first, then... decrease frequency as pain diminishes using 50% rule.
With ACUTE lumbar sp-st, adjust the patient to their _________. tolerance. May only be able to adjust well side initially.
Modalities for ACUTE lumbar sp-st? EMS (IFC, High Galvanic using + for acute), Heat or ice, Cryotherapy first 2 days at home) MSTM – break cycle of hypertonicity
Follow-up modalities for ACUTE lumbar sp-st? Bracing for first few days, Mild stretching in pain free directions, Core strengthening and stretch – especially HAMSTRINGS
Goals of passive and active tx for ACUTE lumbar sp-st Go from mostly passive care to mostly active care over time
ACTIVE care for ACUTE lumbar sp-st ROM, Isometric strengthening, Theraband, Weights, Physioball for stability
Challenge muscle, minimize joint load to spine, enhance joint stability in neutral posture Definition of Exercise – requires whole body stabilization.
Nutritional supplements for ACUTE lumbar sp-st Multi, Mag, EPA-HAD, Co-enzyme Q – all helping ATP, lowering free radicals, and providing substrate for anti-inflammatory eicosanoids
RED FLAGS in LBP some PAIN unrelieved by rest or posture or unchanged after 2-4 weeks tx, Writhing
More RED FLAGS in LBP Colicky or visceral, Previous CA, Fever, FX risk (elder), Malaise, fatigue, weight loss, Progressive neuro impairment
Final four RED FLAGS in LBP on their own slide Bowel or bladder dys., Severe morning stiffness as primary complaint, Unable to ambulate, Repeated failed back surgical or MD tx for back pain or other chronic illness
hallmarks of CAUDA EQUINA syndrome SADDLE anesthesia, Recent BLADDER dysfunction, Severe or prog. NEURO DEFICIT in LOWER EXTREMITY
CES is not fatal but morbidity assoc. with long term effects such as? Bladder infection, Decubitus ulcers, Venous thromboemboli
Referral for CES Decompressive surgery – laminectomy to increase vertebral canal diameter
Herniation, Microdiscectomy, and Laminectomy – still adjust? YES
Three reasons for FACET involvement causing LBP and the best one is? 1. Intra-articular FIBROSIS 2. MENISCOID entrapment (**best!) 3. Phys-mech malpositioning and altered mm activity
Theory that BEST describes joint restriction at the FACET? MENISCOID ENTRAPMENT
Cartilage becomes entrapped between 2 surfaces of facet joint MENISCOID ENTRAPMENT
Effects of meniscoid entrapment Restriction, Pain & inflammation, Spasm or inhibition (weakness), Compensation, DJD
Who, in 1911, first described the lumbar FACET as potential source of back and leg pain? GOLDTHWAIT
Sign of classic lumbar FACET syndrome - movement Pain on lumber hyperextension & DECREASED ROM esp in extension & rotation
Sign of classic lumbar FACET syndrome – tenderness local over facet joint
Neurologic and nerve root tension signs of lumbar FACET syndrome NONE *key!
MacNab's joint body line Intersect posterior to foramen – imbrication. Means line intersect at or before the IVF. Radiograph indication of disc thinning and facet imbrication.
Suspect facet syndrome at L5 S1
RELIEF for lumbar facet syndrome – POSTURAL lumbar FLEXION
SLR in lumbar facet syndrome may or may not be positive. Pain increases with motion, especially EXTENSION and is RELIEVED BY REST. Use these indicators instead.
90 90 position
Back stiffness in AM or with INACTIVITY FACET syndrome OR Ankylosing spondylitis* (differentials for test)
ORTHO exam for FACET syndrome ROTATION, HYPEREXTENSION, KEMP'S, PRONE hyperextension (lion pose). Spondlyoarthropathies also cause pain on extension.
SPRING test for facet syndrome local tenderness at L-S junction with springing over facet causing pain reproduction
**Facet syndrome description Scleratogenous pain, Not below knee, Flexion feels good, NO radicular
**Radicular pain description Dermatomal distribution, Motor weakness-hypOreflexia, down reflex, down sensation
Kleynhans 3 types of facet syndromes: TRAUMATIC...PATHOLOGIC...POSTURAL
REEFERRED pain is also called (haha REEFER...okay nevermind) Scleratogenous
REFERRED vs. SCLEROTOGENOUS pain R: deep, boring, local. Away from posterior articulations, groin, lat thigh, calf. Rarely sensory deficit or nerve root tension signs. S: SHARP, shocking pain, follows course of sciatic or femoral n. Sensory deficit. Positive nerve root tension signs.
What creates recurrent DYNAMIC entrapment of facet meniscus? Disc thins over time, capsule laxity, all allow facets to slide (sublux)
Two states that cause facet imbrication Laxity of facet capsule ligament and-or hypermobility
Lateral entrapment with FIXED deformity Entrapment of the spinal (DRG or root) LATERAL to the spinal canal
When does lateral entrapment with FIXED deformity occur? Disc herniation, Subluxation of posterior joint (facet capsule), or Osteophyte growth
Marked disc height reduction, Retrospondlylolisthesis, Reduction of IVF size, Osteophytes Lateral Entrapment with FIXED deformity
Common presentation of LE with FIXED deformity Buttock & Lower extremity PAIN, EXERTIONAL CLAUDICATION (neurogenic) on one side only.
How to image lateral stenosis CT for patency of radicular canal, MRI
Type of image to map out a disc herniation Discogram
Medical tx for lumbar FACET PAIN Injection, RF ablation, Surgical fusion
For which type of deformity is chiro most effective: dynamic or fixed? DYNAMIC - spinal manip caused improvement in 50% of cases w lateral stenosis (both dynamic and fixed)
How to adjust for lateral stenosis? With FLEXION and AXIAL rotation in pain free direction to open lateral canal and foramen
Exercise for lateral stenosis is important but which one to avoid? ROTATIONAL like golf, racquetball – may increase entrapment
Severe cases of lateral stenosis may require epidural injection
Spondylolisthesis slipped vertebra (Gr.)
SL [SondyloListhesis] is most common at what level? L5
Symptomatology of SL 50% have none
Imaging to confirm SL Routine LATERAL lumbar while STANDING. OBLIQUE lumbar for PARS. F & E views for STABILITY. CT for CROSS sectional.
SL can be bilateral or unilateral. Which is stable? UNILATERAL is STABLE
What will you see with unilateral spondlyolisthesis on xray? UNILATERAL pedicle SCLEROSIS
Grading system that measures the % of listhesis MYERDING – grades 1-5 (5 is 100% complete = spondyloptosis)
Grade1 Myerding 25.00%
Grade 3 Myerding at least 50%
Grade 5 Myerding 100% = spondyloptosis! Yikes.
Slippage of a vertebral body on the vertebra below spondylolisthesis
Developmental (dysplasia of neural arch) causing SL generally not noticed until later into childhood or even adult life
A vertebra may slip following the development of a STRESS fracture
Acquired SL Degeneration due to daily stress of loading, or single or repeated blunt force
Why does lumbar spine develop SL LS joint anteriorly directed shearing with lordosis. Facet joints become unable to resist anterior shearing forces.
Structures that resist anterior shearing forces in lumbar spine FACET joints, pars interarticularis, IVD ***
ISTHMIC spondylolisthesis Separation of PARS interarticularis = UNSTABLE!!!!
Who is susceptible to ISTHMIC SL Atheletes esp gymnasts and divers. Acquired as a result of FATIGUE fx.
Which one is decompression effective for: Isthmic or Degenerative SL Degenerative only. Don't do it on isthmic because isthmic is unstable.
Pain in low back w/ increased lordosis may be Spondylolisthesis = pain/weakness in one or both legs, can't control bowel/bladder
Advanced spondylolisthesis patient appearance/presentation WADDLING gait, Canal STENOSIS affect dorsal column so LOSE proprioreception
Is clinically silent in many adults until midlife spondylolisthesis
Maintains stability of segment in spondylolysis: IVD
Why does disc degeneration make sx appear in spondylolisthesis? Disc was main source of stability. Increasing slip = LPB and leg pain
olisthetic downward slipping
SLIP progression starts after _____decade, coinciding w/? third decade, marked disc degeneration at olisthetic level
SLIP progression is associated w/ clinical signs of ? And? mechanical instability and spinal stenosis = incapacitating LBP + sciatica
Describe 3 points about Degenerative Spondylolisthesis: After 20 y.o., Spinal stenosis & surgery are both maybe's
SLIP progression occurs in ~20% of all adults with ISTHMIC (unstable) spondlyolisthesis
PLIF Posterior Lumbar Interbody Fusion: rods, screws, bone graft
TLIF Transforaminal Lumbar Interbody Fusion: preferential to PLIF, less scarring and less invasive
There are no adjustive procedures to reduce a spondylolisthesis. TRUE.
Kyphoplasty Balloon, trying to restore IVD height
Vertebroplasty no height restoration attempt is made
100% slippage of one segment on another spondyloptosis
As a chiro, you cannot reduce the amount of listhesis. What can you do? Direct manip at dysfunctional joints and not the level of the spondylolisthesis. Use HVLA at segs above and below. Drop work on pelvis is GOOD! Prone lumbar adjusting is bad (Gonstead)
Additonal methods to use for spondylo symptom relief Activator, SOT blocking, Drop work on pelvis, Logan basic
pt has pain at TL junction which refers to LS junction... UNSTABLE
Sx and etiology of thoracic outlet syndrome pain, numbness, tingling, weakness, or coldness in upper extremity caused by pressure on nerves and/or blood vessels at TO
What creates pain, numbness, and tingling of TOS specifically? pressure on SENSORY nerves
What creates weakness & fatigue of TOS specifically? pressure on MOTOR nerves
What creates swelling and coldness in the arm and hand in TOS? pressure on the BLOOD VESSELS (constriction)
The brachial plexus passes between what two muscles? Anterior and Middle scalenes
The brachial plexus passes between what two bones? Clavicle and first Rib
After it passes through the mm and bone gauntlet, what mm does brachial plex pass behind? Pectoralis
TOS can be caused by what two bone anomalies? Cervical rib or Elongated TP
TOS compression repetition posture Arms held overhead in repetitive activities
TOS cervical rib or old clavicle fx affect limits vessel and brachial plexus space
TOS violent injury example seatbelt in car wreck, also may tear SCALENE mm and form scar
TOS postural cause slouching forward and dropping shoulders – tension on lateral neck mm
TOS common complaints Shoulder, arm, forearm, hand and chest pain. Numbness/paresthesias in lower cervical roots (C8-T1), LOWER trunk of brachial plex affected.
TOS ortho tests ROO'S, EDEN'S, WRIGHT'S, ADSON'S/ADSON'S REVERSE
test used as a screen for BLOOD SUPPLY TO HAND only Allen's test...is NOT a thoracic outlet test.
TOS treatment CMT-D cervical + thoracic, MSTM, HMP/Pulsed ultrasound/EMS, Vibration, Stretch & Strengthen, Exercise for posture and balance
TOS medical mgmt Meds, PT, Surgery = SCALENECTOMY
T4 syndrome levels One or more levels b/w T2-T7 affected w/ T4 almost always affected.
T4 syndrome sx Paresthesia, vague pain in one or both UE in GLOVE-LIKE fashion.
T4 syndrome involved areas Hand, hand and forearm, or entire arm
GLOVE-LIKE paresthesia or vague pain in hand, forearm or arm T4 syndrome (not Guillan-Barre for this class but can be d/dx)
Pain in upper or lower thoracic spine; WORSE AT NIGHT, awaken to sleeping on BACK T4 syndrome – can occur daily or 1-2x per week.
T4 sx are varied. Why? Sympathetic chain ganglia
T4 complaints of headaches Dull occipital to pressure throughout head (cervicogenic/tension). GI and TMJ co-factor in.
d/dx for T4 syndrome TOS & Upper crossed syndrome & Carpal tunnel
T4 irritants driving, reading – pt must shake or rub affected area to relieve sx (FLICK SIGN)
T4 patient presentation forward head, large upper traps
T4 physical exam findings +ROO'S test, Hypomobile upper thoracic esp T4 and costo-transverse jcns, Springing on ribs painful.
T4 areas of chiro exam findings T2-7 hypomobile segments esp T3-4 and T4-5. Springing on these segs recreates arm sx often. Costo-transverse jcns hypomobile and tender.
T4 CLINICAL exam Basic functional exam for all spinal levels is neg or vague. No neuro deficits. No dural tension signs.
T4 Treatment CMT-D thoracic, including costotransverse and costovertebral rib jcns. Mobilize ribs 1-3 at costot. And costov. Joints.
T4 spinal manipulation from T2-T4 can affect the _____ system. sympathetic nervous sys (due to connection to symp chain gang)
T4 IAOM recommendation Soft tissue and local oscillating joint mobilization, hot packs, EMS over affected segs, Postural stabilization
T4 tx home instructions Scalene stretch w/ self mobilization of 1st rib daily, Upper back strengthening w/ isometrics, Breathing ex, Low intensity arm ex (aerobic)
Shape of thoracic vertebral body WEDGE (cervical and lumbar are rectangular)
Difference between anterior and posterior aspect of thoracic vertebral body Posterior is 1-2 mm higher
Purpose of thoracic wedged vertebrae KYPHOSIS rigid primary
Prolonged ____loading of thoracic verts may exaggerate kyphosis. axial
Superior FACETS of thoracic Flat oval superiors face posterior and superior at 60 degrees w/ slant to match inferior facets meeting them below
How do superior thoracic FACETS appear from above? As an arc of a circle which has an axis slightly anterior to the vertebral body. (see pg 5 lecture)
Common ERROR adjusting thoracics At 80 deg instead of correct 60 degrees – causes facet jamming and articular trauma
Ntq: Thoracic DISC SPACES are PARALLEL (unlike cervical and lumbar that are wedge shaped)
Ntq: The primary thoracic KYPHOSIS is produced by the BONE because the wedging is of bone, not disc, in the thoracics
Ntq: Secondary cervical and lumbar LORDOSES produced by FIBROCARTILAGE
Ntq: not a test question
Ntq: Why is thoracic FLEXIBILITY MINIMAL DISC HEIGHT compared to vertebral body height is LESS than that of any spinal region
costoVERTEBRAL vs. costoSTERNAL stability cV: highest stiffness in LATERAL and lowest on superior and inferior loading. CS: opposite. High resistance on VERTICAL, low against A-P
Why could you easily sprain a costoVERTEBRAL/TRANSVERSE jt w/ a supine thoracic placed to far lateral?
Is the costoVERTEBRAL joint a synovial joint YES (except first rib and floating ribs)
The thoracic spine has a high incidence of CORD DAMAGE assoc. w/ STRUCTURAL DAMAGE
The thoracic spine is a common site for (fracture type?) BURST fx – anteiror centrum in lower region only
Major source of supply of sympathetic fibers thoracic spine
Is clinically unstable during flexion thoracic spine
Name the D/dx of thoracic spine disorders...VoS Has Cost Tons of friggin' Time VoS Has Cost Tons of friggin' Time: Vertebral dysfunction, Scheuermann's, Herniation, Costovertebral dysfunction, Thoracic fractures, Tumors
Cord compression of thoracic can lead to [4] Dorsal column (proprio) loss, Bowel/bladder sx, Spastic ataxia, Hyperreflexia
Common biomechanical concerns of thoracic Hyperkyphosis – Flattening – Scoliosis
Percentage of thoracic disc herniations 2-3%
Thoracic disc herniation population males in 5th decade
MOST COMMON motion segment to herniate in thoracics T11-12
Pain description of thoracic herniation Asymptomatic or BAND-like, may radiate to abdomen, flank, groin
Pain of thoracic disc herniation ACUTE vs CHRONIC A: bilateral [GIRDLE distribution], C: unilateral
Brown-Sequard syndrome Loss of same side motor/fine touch/vibration & opposite side P & T
Brown-Sequard syndrome cause HEMISECTION of cord = paralysis & ataxia
Where does loss of Pain & Temp in Brown-Sequard occur 2-3 segments below hemisection of cord
Thoracic disc herniation d/dx Intercostal neuralgia – Ank. Spondylitis – Mets or Tumor – Neurofibroma – Infection – Viscerosomatic Reflex
3 predisposing thoracic disc herniation factors 1. Previous injury 2. Degeneration 3. Healed osteochondrosis (Scheuermann's)
What exacerbates TDH Neck flexion, Coughing, Straining
What palliates TDH Lying down supine (with wine)
An EXTRUDED thoracic disc may cause _________ . Myelopathy
Why aren't there many (2-3%) thoracic disc herniations? More stable and moves less due to rib attachments (can't rotate)
Which is quicker to resolve: cervical, thoracic, or lumbar extrusion Thoracic – acute phase w/ extruded disc. Sx are from inflammation rather than compression
2 ligaments which can compress cord PLL and Ligamentum Flavum
Numbness in lower limbs is most common initial sx of thoracic MYELOPATHY
All patients with thoracic MYELOPATHY have MOTOR weakness & difficulty WALKING
Does thoracic myelopathy cause spastic or flaccid reflexes?
NON-operative medical mgmt of thoracic MYELOPATHY rest, low activity, gentle exercise, Narcotics, NSAIDS, ice, injections, manual manipulation,
VATS Video Assisted Thoracic Surgery – KEYHOLE, minimally invasive. SCOLIOSIS
Chiropractic mgmt of Thoracic DISC herniation CMT-D, F & D, Decompression (no supine traction if acute, hypertonic, hypermobile)
Movement that exacerbates thoracic cord compression/stenosis FLEXION (relieves cervical and lumbar, but worsens thoracic)
Characteristics of SCHEUERMANN'S SCHMORL'S nodes, vertebral body WEDGING, and SMOOTH kyphosis
Tight _____ are often noted w/ SCHEUERMANN's tight hams
osteochondrosis of vertebral plates/epiphyseal ring SCHEUERMANN'S
SCHEUERMANN'S is also called juvenile kyphosis – males + females @ puberty. 3-4 contiguous mid-low thoracic verts
Where are the common Scheuermann's sites of pain 20-60% patients have pain @ APEX of kyphosis, CT junction, INTERSCAPULAR
Why isn't Scheuermann's considered a Gibbous formation Because affects 3-4 contiguous segments
Describe Scheuermann's Little change w/ posture. HYPERLORDOTIC lumbar. Tight HAMS + PECS. Paraspinal myospasm
Scheuermann's can be asymptomatic and unlikely assoc. w/ sports, except when activity creates superimposed injury.
for tough thoracic areas, use (modality) 3 min of pulsed ultrasound (or continuous) on either side
Acute thoracic sprain/strains are usually from athletic injuries
Thoracic Sprain/Strain (TSS) is also called Acute Traumatic Spondylitis
3 Main goals of thoracic sprain strain Reduce pain/swelling by vasoconstriction, compression, elevation. Enhance healing (diet/exer)
Most frequent cause of INTERCOSTAL NEURITIS infection with Herpes Zoster [SHINGLES]
3 possible d/dx of intercostal neuritis Shingles *mc, epidemic pleurodynia, tumors, Ruptured discs (chem radic)
Why may viscerosomatic sx arise to thoracic spine Vague, simulating cardiac or gastric conditions b/c thoracic is sympathetic source
Fixed misalignments upper trunk shoulder girdle, esp w/ scapulae
modalities for fibrositis of shoulder caused by overhead work ART/Graston, Facilitated stretching, Continuous US, HMP, Vibration
Area prone to FIXATION more than any other in spine LOWER THORACIC = T9-12
Why T9-12 fixation prone facet plane change @ TLJ, compressive forces, altered stiffness, lack of support mm, floating ribs suck
TL junction syndrome causes T12, L1 involved: Painful minor intervertebral dys (PMID), prolapsed disc, herniation, REFERRED pain
Patients almost never complain of TL junction pain. Why? pain is REFERRED to low back, abdomen, trochanter bursa, pubic/groin/testicular pain
TL junction syndrome on radiograph Rare (T11-L1)
Palpation for TL junction syndrome Only perceived as tender TL if palpated
2 types of CENTRUM FRACTURES: 1. Compression... 2. Comminuted
Where do most compression fx of thoracic spine happen? ANTERIOR (due to bending moments and axial compression)
Where do thoracic fx most commonly occur T12 transitional area, then kyphotic angle – COMPRESSION w/ collapse
Which is from violent force: compression or comminuted? COMMINUTED
What is the red flag when view comminuted vetebral fx? posteriorly displaced pieces of bone into central canal (loss of motor)
Components of vertebral failure LIMIT Load on spine divided by VFL (bone mineral density + trabeculae)
Meds for osteoporosis Bisphosphonates: Fosamax, Boniva, Actonel, Reclast = slow bone loss
Evista selective estrogen receptor modulator used only in women to slow bone loss and cause some increase in bone density
Natural hormone that helps reg Calcium; helps slow bone loss CALCITONIN (Calcimar or Miacalcin) – also relieves compression fx pain
PTH hormone injection High risk fracture patient. Teriparatide, Forteo
Post menopausal hormone for women's bone density Denosumab (Prolia). Injection every 6 mo
VCF Vertebral Compression Fracture
Associated w/ minimal trauma (fall). 700,000 per year! VCF – starts downhill slide to premature death
Each VCF reduces forced vital capacity by 9.00%
Leading causes of death in VCF patients COPD and pneumonia (chronic pain, sleep disturbed, kyphosis)
Women w/ at least 1 VCF are up to 1/3 more likely to die early from pulmonary disease, almost 2x as many as cancer
History for patient w/ VCF Acute back pain w/o much trauma, Progressive kyphosis and shortening
Plain films will show VCF One or more ANTERIOR compression fractures in OSTEOPENIC bone
Conservative VCF tx Pain meds, Bed rest (morbidity assoc as 1% a week), Jewett hyperextension orthosis brace, PT
Aggressive VCF tx To control kyphosis/lordosis: VERTEBROPLASTY or KYPHYOPLASTY
VERTEBROplasty (web definition) Vertebroplasty involves injecting a cement mixture into the empty spaces via trocar within weakened vertebrae to strengthen them and provide pain relief.
KYPHOplasty (web def) same as vertebroplasty but attempts to restore HEIGHT and ANGLE OF KYPHOSIS
Kyphoplasty attempts to restore _________ **** HEIGHT & ANGLE OF KYPHOSIS
SOTO-HALL used when? Ligament or Fracture suspected
How would you tell a positive Soto-Hall? Pain felt acutely when spinous process of injured vert is reached b/c it pulls on posterior ligaments from above.
Fracture vs. Infection in a vertebra Fx: disc present Infect: disc gone or thinned
Tumor (+) test for cord NAFFZIGER's esp for spinal menengioma
Why radicular pain with spinal cord tumor Fluid pressure of CSF above tumor builds, compresses sensory structures
Who NOT to do Naffziger's for spinal cord tumor test? Geriatrics or anyone w/ atherosclerosis. (stroke)
Naffziger's pressure over jugular – see Evans page 157. SOL in spine.
Scoliosis and girls 8x more likely and 5x more likely to need treatment
80-90% of scoliosis is Idiopathic!
Causes of scoliosis besides idopathic Marfan's, birth defects, muscular dystrophy, cerebral palsy
SECONDARY causes of scoliosis are ______ disorders. INHERITED
Example of 2nd cause of scoliosis Ehlers-Danlos (collagen synth disorder), Marfan's, Homocystinuria, Neurofibromatosis, Dysautonomia (Riley-Day), Tethered cord, Klippel-Feil
MARFAN'S and scoliosis CT disorder – pectus excavatum/dural ectasia/myopia/lens dislocation/heart prob/cold extremites
TETHERED CORD and scoliosis Shown to cause it in one study
What weird disease was on Boards III for scoliosis 2nd cause Neurofibromatosis
Familial dysautonomia and scoliosis Reily-Day: Pain Insensitive, Unable to produce tears, Poor grow, Labile B.P.
Werdnig-Hoffman dz and scoliosis severe infantile spinal mm atrophy
Fredrich's ataxia and scoliosis inherited demyelinating dz
Musculoskeletal 2nd causes of scoliosis Leg length difference, Developmental hip dysplasia, Osteogenesis Imperfecta (brittle bone), Klippel-Feil
One in ____ females have some sign of scoliosis. 1 in 9. 4% of general population
_________ scoliosis is multifaceted and can compromise body's 5 systems. Idiopathic!
How does idiopathic scoliosis affect body? Deplete nutritional resources; damage major organs incl. Heart and Lungs.
Idopathic scoliosis not truly pathological until... Curve reaches 20 deg. & pt. Has a RIB HUMP w/ FIXED curve (rotation and lateral flexion)
3 determinates of scoliotic curve progression Gender, Growth potential (age), Magnitude of curve @ diagnosis
In all cases, females have a curve progress. ___x greater than males 10x
the likelihood of curve progression depends of size of curve and growth potential (age) of patient
Position of cord in scoliotic spinal column Cord displaced towards CONCAVE side to maintain straight line and does NOT rotate w/ vertebrae
The cord tries to stay upright in scoliosis. Considerations? Convex side nerves: GREATER stress, TRACTION, more distance to IVF. Likelihood of ENTRAPMENT.
On which side of the scoliosis are the nerves constantly vexed? conVEX- those nerves are VEXed at every turn.
2 types of scoliosis and which is worse Structural (worse) and functional
Test for scoliosis Adam's positin
STRUCTURAL scoliosis Rotation + Lateral Curvature, w/ rib humping on one side. Progressive
Functional scoliosis Fixed rotation does NOT occur and curve usu. NON progressive. Postural or Compensatory
Postural vs Compensatory functional scoliosis P: disappears on forward bending C: short leg compensation
Most common form of scoliosis ADOLESCENT IDOPATHIC
Measuring scoliosis Cobb on xray. Tanner & Risser grading.
Degree of curve when surgery necessary > 40
Degree of curve when BRACING used 24-39 deg
BRACING scoliosis effectiveness Under 16 y.o., stops progression in ~ 80% patients. Some relapse.
Is physiotherapy effective for scoliosis? no
74% braced success! 34% observation success. 33% electrostim success Scoliosis, so don't use elec cause it has the same success rate as observation
contraindications for VATS fusion to correct scoliosis pts who can't tolerate single lung vent, w/ severe lung dz/inf., previous anterior surgery, double thoracic curves
Medically, most effective method of tx based on evidence SURGERY to stabilize and prevent progression
Prevalence of backache in untreated scoliosis 2x avg
Why was scoliosis assoc w/ breast cancer before Mistakenly. It was the # of xrays they gave the women (duh)
Scoliosis and chiropractic evidence
Could chiro be effective to ease progress of scoliosis As a restoration of proprioreceptive flow at segmental level, yes
Adjustment vectors for scoliosis Reduction of rotation and lateral flexion, also convexity
Bracing scoliosis SpineCor – soft brace improved some 57%
Can bracing help adult scoliosis? Ed Cleere, DC says yes – stop curve pressures & reverse vert deformity
Theory behind bone remodeling brace Pressure to OPEN wedge cause bone remodel triggered by FLEXURE repetition loads
Ocular Vestibular Therapy for spine/scoliosis Vestibular Ocular connection for central postural control. Nystagmus demonstrated in scoliotic patients
VENG Video Electronystagmography Convexity of scoliosis matches labyrinth side of caloric response/nystagmus
Exercises for scoliosis 3D respiration to strengthen spinal+pelvic mm, reshape ribs, inc vital capacity of lungs
Nutrition for scoliosis Depressed trace minerals selenium, zinc, iron and absorption problems
How long does Aetna give a patient to demonstrate improvement 2 weeks. If working, then 30 days. No maintenance nor palliative allowed. Not allowed for scoliosis.
What does Charles Lantz DC PhD and Jasper Chen DC study say Chiro is not effective for reducing severity of scoliotic curves
3 physical test for MENINGITIS Brudzinki's, Kernig's (leg bent, opisthotonus +), Trousseau's line
Sign for sciatic nerve root tension Laseuge's
Ankylosis chest expansion test 2” difference is negative sign (less in females). Positive sign little or no difference in expansion on inhalation (ankylosis or spondylitis)
kind of pain with facet syndrome sceratogenous, usually not below knee
radicular pain dermatomal, motor weakness, hyporeflexia, diminished sensation
disc degeneration can cause retrolisthesis and anterolisthesis
Should you concern with anterior osteophytes on vert? no
facet adjustments long axis distraction w/ Dutchman's roll on F&D, side posture ext
fixed deformity advanced degenerative change
lateral entrapment of fixed deformity neurogenic claudication
Make a letter of medical necessity and/or get Pre-authorization (discogram, bone scan)
Cannot send a patient for a facet injection right, you cannot – it's a therapeutic modality
radial frequency ablation burns nociceptors in joint capsule (but they grow back)
surgical fusion of facet joint no
Best chiro outcome situation for facet syndrome Dyanmic acute
spondyloLISTHESIS is near and dear to Dr. Loia because he has one! L5 is resting on sacrum and has bone bar/spur across front. Fused. So study those cards ;-)
SpondyloLISTHESIS – figure out if it's stable or unstable
spondyloLISTHESIS unilateral stable
SpondyloLISTHESIS grade IV Myerding 100% spondyloptosis – pt can still walk!
SpondyloLYSIS stress fracture through NEURAL ARCH (gymnasts, football, weightlifters)
SpondyloLYSIS falling off ladder, landing on feet, anterior shearing forces
ISTHMIC spondylo Can have disc herniation. Do not use decompression. UNSTABLE
spodylo w/ pendulous abdomen lumbar TRUSS support
adjustment for spondylo scoop move – will NOT reduce spondylo. There is none. May give relief by unloading facets but won't reduce spondylo.
Active tx spondylo keep CORE strong, reduce lumbar lordosis
Risk of spondylo canal STENOSIS
19 year old with bilateral paresthesias into feet on flexion SpondyloLISTHESIS – was so flexible she could put palms behind ankles. No adjusting. Had surgery.
spondyloLISTHESIS management – direct manipulation at? Dysfunctional joints and NOT at the level of the spondylo **test question!
the only muscle proximal to knee innervated by common peroneal n. SHORT head of biceps FEMORIS
3 causes of LUMBAR RADIC Disc HERNIATION & DJD & Congenital STENOSIS
Presentation of lumbar RADIC Antalgia, Spasm, MRS's = acute hyPER, chronic hyPO
90% of lumbar RADIC at levels L4-5 and L5-S1
Affect nerve at same level Foraminal (subrhizal) & Lateral disc herniations
Affect nerve ONE LEVEL DOWN Central and Paracentral hernations
FEMORAL n. muscles Iliacus, Quads, Sartorius, Pectineus
OBTURATOR n. muscles Gracilis, Adductors
TIBIAL n. muscles ALL posterior calf (gastroc, soleus, plantaris, popliteus), TOE FLEXORS, tibialis POSTERIOR, SEMIMEM
Nerve roots of pretty much every thing in the foot S1, S2
SCIATIC n. muscles Biceps FEMORIS (short & long heads)
COMMON peroneal n. muscle SHORT head of biceps femoris – only mm proximal to knee innervated by C.P. N
Only muscle proximal to knee innervated by common peroneal SHORT head of biceps femoris (split innervation by sciatic and c.p.n.)
DEEP peroneal n. muscles Tibialis ANTERIOR and toe EXTENSORS, peroneus TERTius
SUPERFICIAL peroneal n. muscles Peroneii bros. (tert is sooo superficial)
MEDIAL and LATERAL plantar n. muscles Bottom of foot = Abductors, Adductors, Lumbricals, Interossei, Brevis
Piriformis roots
LUMBOSACRAL PLEXUS neurologic levels T12-S1
LUMBOSACRAL PLEXUS muscles and roots Iliopsoas (T12-L3: main hip flexor), Quadriceps (L2-L4: hip flex, knee extend), ADDuctors (L2-L4: hip add)
Neurologic level L4 Tibialis ANTERIOR predominates; dorsiflexion & inversion
If Tib Ant (L4) is damaged, can you still invert foot? YES = Tib POSTERIOR inverts foot
Neurologic level L5 BIG TOE Extensor hallucis longus, Extensor DIGITorum (heel walk), Gluteus MEDIUS (#1 adductor)
Most powerful abuctor of hip Gluteus MEDIUS from L5 (external rotation & abduction)
Neurologic level S1 Peroneus LONGUS (plantar flex & evert), P. BREVIS (toe walk), Gluteus MAX (extends hip)
S1 on the bun Glute MAX
Imaging for Lumbar radic Lateral plain film, MR, CT, H-reflex, EMG paraspinals and peripheral mm innervated by that root, DSEP
How long does it take for SHARP waves to appear on EMG 7 days
Why isn't an NCV appropriate for lumbar radic would have to cross the entrapment site :-(
Electrodiagnostic test specific for S1 only H-wave
Entrapment sites of lower extremites Inguinal lig, Adductor canal (Hunter's), Fibular head, Anterior compartment (leg), Anterior & Posterior tarsal tunnels (ankle)
Entrapment at INGUINAL LIGAMENT (2) Femoral n. & Lateral Femoral Cutaneous n.
Describe femoral n. entrapment @ inguinal ligament Relieved by flexion & external rotation of hip, Down motor & sensory, anterior knee pain (saphenous n.), Anterior thigh & med leg dysthesia
Femoral n. roots L2,3,4
Describe Lateral Femoral Cutaneous n. entrapment at inguinal lig MERALGIA PARESTHETICA = ant + lat thigh burning, tingling/numb > walking standing hip extension. Increase sx when lying prone. Improve w/ sitting unless tight belts or overweight
Meralgia paresthetica entrap of LFC n. at inguinal ligament can be intra-pelvic or extra-pelvic
Causes of Intra-pelvic compression LFC n. (meralgia paresthetica) Pregnancy, Abdominal tumors, Uterine fibroids, Diverticulitis, Appendicitis, AAA
EXTRA pelvic entrapment causes on LFC n (meralgia paresthetica) Trauma to ASIS region [seatbelt, crash, tight clothes], Prolonged sitting/standing, Pelvic tilt causing leg length discr. Diabetes.
SAPHENOUS n. entrapment Pain in saph distribution, NORMAL motor fcn. Tenderness over **Adductor canal (Hunter's)**
OBTURATOR n. entrapment Pelvic trauma/fx, Delivery [baby head compress pelvis], Tumor [mass effect], Arthroplasty [hip], Adductor Magnus in athletes
D/dx between saphenous n. and L4 radiculopathy **test Tibialis anterior is L4 and would have diminished motor & patellar reflex.
Sx of Obturator n. entrapment MEDIAL thigh pain, Exercise related groin pain, Weakens w/ exercise, Diff ambulation
COMMON peroneal n. entrapment by fibular HEAD Fibular HEAD: ankle sprains, knee disloc, tibial/knee/hip surgeries, Baker's cysts, tumors
COMMON peroneal n. entrapment by fibular neck ANTERIOR COMPARTMENT SYNDROME
Describe anterior compartment syndrome Fibular neck: internal increase in compartment vol. By internal or external forces.
Causes of anterior compartment syndrome Ex: Tight ski boots, burns, casts Int: Hemorrhage/trauma, crush fractures, rhabdomyosis, weights
Landed on knee: foot drop + numbness lateral midcalf to dorsum. 5Th digit spared DEEP peroneal n. entrapment: High volt Galvanic (+), RICE, Rehab both legs
piriformis entrapment sciatic nerve
inguinal ligament femoral n. and lateral femoral cutaneous n.
What peripheral n. can be entrapped at Hunter's canal Saphenous n. is Sensory (adductor tubercle)
Anticoag therapy d/t pulmonary emboli. Ant thigh + medial leg pain, paresthesia D/dx: femoral n. entrapment sites (inguinal, psoas). She has weak hip flex so not inguinal. Fem n. L2-4. Retroperitoneal hematoma removed. Anterior femoral cutaneous, Saphenous, L4, or Femoral. Retroperitoneal psoas abcess damaged femoral n.
Can you adjust someone on anti coagulant therapy yes, gently
L5 radic electrodiagnostic tests MCNV (must cross area of entrapment. If neg, no entrap). H-wave (S1). Sensory NCV (sural n. mimics S1, saphenous mimics L4). Needle EMG (L4-S2: look for positive fibrillation and sharp waves = radiculopathy)
Quad roots L2-4
Gastroc roots S1-S2
Lesion to L5 covered all the mm tested in Case 3 L5 radiculopathy: Valsalva's neg, ice, do F&D protocol I, adjust!
LBP and right leg pain case. Golf, exacerbated leaning over sink Pain increases during FLEXION and RLF. D/dx: Lumbar sp/st, radic, disc, spondylolisthesis, SOL, peripheral entrap, double crush, claudication
Foot drop muscle and nerve roots Weakness of TIB ANTERIOR [L4-S1 roots]
Foot drop etiologies Prior back injury (root lesion), double crush, sickle cell trait, UMNL hemiparesis, Dislocation/sublux of knee damages fibular n.
Foot drop nerve pathway Sciatic > Common peroneal > DEEP peroneal
Foot drop sparing that would point to peroneal nerve lesion Tibial innervated mm spared (plantar flexors, ankle inverters) means peroneal n.
Findings of golfer: Flex + RLF limited, Pain L/S on extension 3/5 peroneii L&B, EDB, Dorsiflex weak, reduc sensation, Patellar + Med ham reflex reduc. L4 paracentral herniation
Ortho tests on golfer for foot drop and lumbar Valsalva's, SLR, Nerve tension signs, Hyndman's L4 paracentral herniation
Special tests on golfer Plain films, MRI, CT, EDX L4 paracentral herniation
Golfer EDX – EMG fibs and sharp waves tib ant, peroneus longus, EDB, paraspinals, short head b. femoris L4/5 disc herniation affecting L4 root but more central hitting L5
FLEXION and LATERAL FLEX pain sounds like a RADIC
Would a contained disc herniation, Valsalva's should cause a radic. A non-contained can but doesn't have to.
Hyndman's test Bechterew's, Linder's, and Valsalva's simultaneously. SLUMP test for equivocal sx of disc herniation or malinger
Which disc responds better: contained or non-contained NON -contained
On the golfer, what was redundant? Electro studies because clearly herniated on MRI
Freqency for acute radiculopathy 3x week for 6 visits the OA's {VAS, Pain diagram}, IFC, MSTM, ice, cold laser
Freqency for acute radiculopathy 3x week for 6 visits the OA's {VAS, Pain diagram}, IFC, MSTM, ice, cold laser
Disruption to the normal integrity of the IVD disc herniation – lumbar herniations displace the nucleus.
IVD functions Spacer...Shock absorber...Motion unit
Why do annular ligaments bulge over time Disc dehydrates and redundant annular ligaments bulge. Can crack/tear w/ nuclear dehydration.
DDD Discogenic Spondylosis (DDD = degenerative disc disease)
Cause 1 of SPONDYLOSIS loss of hydrostatic mech due to decreased proteoglycans and presence of inflammatory agents
Cause 2 of SPONDYLOSIS Vertebral endplates degenerated as absorb compressive axial loads
Cause 3 of SPONDYLOSIS Decrease in Type II collagen and elastic fiber proliferation
Healthy discs transmit axial loads from the _____ of the endplate. center (spokes)
Degenerated discs transmit axial loads more from the ______ periphery
With axial overload, which first: endplate fx or disc rupture endplate fx first, testimony to strength of IVD even when partial separation of annular fibers
Loss of normal tissue tension when dehydration Subluxation = osteophyte formation, foraminal narrowing, mechanical instability, pain
Symptoms of LDH divided into [2]: SEGMENTAL and NEURAL symptoms
EMG for lumbar disc herniation shows: (+) fibrillation potentials and sharp waves = radic
MNCV H-wave S1 only
Segmental sx of LDH 1. LBP mainly, pos to buttocks & legs. 2. Unilateral usually 3. Local anatomic disruption
Why is referred pain from LDH often mislabeled as source of pain Nerve serving HD originates in same segment of the peripheral n. going to the buttocks and leg. Afferents converge from embryo/scleratogenous distribution pattern (buttocks and legs)
Cause of referred pain from LDH Irritation to sensory n.'s of low back, pelvis, and thigh.
Irritating chemical released when LDH TNF and substance P
LDH pain rarely radiates below the ______ knee
Quality of LDH pain Deep, boring, and poorly localized
Leg pain and weakness resulting from LDH Stretched annular fibers rupture, allow pressure of nuclear material to compress neural tissues
When herniated disc compresses passing nerve root, it causes Electric, shooting pains down the leg!
LHD typically cause _____ or ______ Sciatica or Radiating leg pain
Radiculopathy Discopathic lesion or spondylophyte causing foraminal impingement of the exiting nerve root
Disc PROTRUSION Broad-based or asymmetric bulging w/ an intact annulus. Indicates disc degeneration.
Disc displacement of 90-180 deg of the disc circumference Broad-based
Presence of disc tissue beyond the edges of ring apophysis Bulging disc
Lateral distance > A-P distance Protrusion
A-P distance > lateral distance Extrusion (>AP)
Transligamentous disc Extruded (>AP) annulus tear all the way through, allows disc material beyond boundary but still connected to parent
Axial plane of compressive force to dorsal columns, PLL, and dural sleeves Central & paracentral [one level down]
Central and paracentral axial compression affects Dorsal columns, PLL, Dural sleeves one level down
Axial plane of compressive force to DRG and nerve root at same level Foraminal (subrhizal) & Lateral disc herniations
End stage of extruded disc, herniated material separates completely Sequestered free fragment
2 Uncontained disc herniations (s.u.e.) extruded and sequestered (s.u.e.)
Contained disc types bulge, herniation, protrusion, focal
Disc type requiring open surgical tx Sequestered
Disc type that needs conservative tx first Extrusion (surgery may be option later)
Which responds better: contained or uncontained Uncontained due to resorption. Both respond to chiro + exercise
Lower lumbar segments, central herniation may cause S1 radiculopathy (do an H-wave to find out)
Central (posterior) protrusion above 2nd lumbar vertebra May compress cord itself or result in SPASTIC motor weakness
Posterolateral (same as paracentral) affects nerve one level down (central and paracentral are called posterior and posterolateral here)
Subrhizal protrusion Foraminal: flexed position. Affects nerve root ABOVE level of herniation (hence, same level). Most common = L4.
Describe subrhizal/foraminal protrusion sx Flexed (subrhizal) position. L4. Femoral or Sciatic n. radicular pain. Prone sleep esp painful.
Extra-foraminal/Far Lateral herniation
Causes of upper lumbar level spinal nerve root compression Beneath or Far Lateral to intervertebral joint
D/dx for Sciatic and Radicular syndromes: [5] LHD, Spinal stenosis, Piriformis syndrome, Spondylolisthesis, Visceral involvement
your ass, your guts, movement, squeezing, a disc Sciatica and Radicular d/dx: piriformis syn, visceral, spondylolisthesis, stenosis, LDH
MC level of lumbar herniated discs L4-5 (56.8%) and L5-S1 (40.8%)
LHD most present in ages 18-45 b/c most active set (weekend warriors)
Presentation of LHD Acute, severe leg pain or numbness preceded by prodrome of back or buttock pain
LHD is not necessarily associated with injury
Pain stage of LHD Acute for several weeks, gradual resolution
Sudden, severe pain in back shooting down to foot LHD
Lifetime accumulation award LHD
Provocative for LHD Look for ANTALGIA. Flexion, coughing, sneezing
Palliative for LHD recumbent position w/ knees flexed
Numbness in LHD can be seen in one ________ dermatome
Muscle weakness and LHD may be present
ANTALGIA of LHD clues M-int and Lateral Lean away, Subrhizal flexed forward
Central disc lesions tend to produce ______ and ___ pain. both low back and leg pain = central
Lateral disc lesions tend to produce Lateral for Leg only
Psoas L1-L3 radic
Tibialis Anterior L4-5 radic
Extensor Hallucis Longus L5 radic
Flexor Hallucis Longus S1 radic
Peroneii Superfical peroneal n.
MM tests for lumbar disc herniation Heel (L4-L5) or Toe (L5-S1) walking, Dorsiflexors, Plantarflexors, Weakness in great toe dorsiflex (L5), Patellar or Achilles hyper
Special tests for LDH MR, CT, Myelogram, Discogram, EDX (H-wave/H-reflex, EMG)
Radiographic contrast dye injected into disc then CT Discogram
Information from a discogram Confirm disc as source, Visualize deterioration, Test pressure resistance, Surgical road map
Chiro mgmt for LDH w/ radic Rotational adj w/ LAD and decompression. F&D, Mackenzie, L/S supports, Nutrition, Exercise, Rehab
When to refer out a LDH symptom exacerbation
Most common procedure for LDH microdiscectomy (fusion is less common)
After microdiscectomy... follow up w/ manipulation, exercise, and lumbosacral support
OA's for LDH Revised Oswestry, Roland Morris
How often to complete OA's during acute phase of LDH two week intervals
What percentage of LDH is resolved within 3 mo 73.00%
Goal of spinal surgery Decompress disc and stabilize area – 40% success rate
Surgery and relief of sciatia
3 indications for lumbar disc surgery Bowel/bladder loss of control, Weakness in important leg mm., Leg pain frm nerve pressure
Surgery is optimal for ______ produced by LDH leg pain
IDET IntraDiscal Electrothermal Annuloplasty – burns nociceptors in disc (lasts 6 mo.) Poor outcome.
Designed to eliminate problems w spinal fusion and maintain motion Artificial disc surgery. Maintains motion ergo reduc potential for adjacent level disease
SB Charite III Prosthesis modern artificial disc implant
Laminotomy bone window
Laminectomy lamina removed completely
SI sprain causes Hormones softening ligaments during preg, Occupation (bending, lifting), Pre-existing DJD
Tx for SI sprain Sitting, recumbency, SI supportive truss, Aprrox restricted motion and adjust into pain free direction
Pt presents w/ inability to straighten up to erect posture after having bent or stooped over SI sprain – tears fibers, focal pain in one motion.
Conservative mgmt for SI dysfunction Manipulation (SOT blocking, Logan), Truss, Modalities, Nutrition, Limited bed rest on firm mattress
Piriformis fcn abduction and lateral rotation of thigh
Piriformis syndrome patient CC Deep pain in buttocks, made worse by by sitting, climbing stairs, or doing squats
Cause of piriformis syn pain Sciatic n. is irritated, causing numbing and tingling along its course to leg and foot
Medical mgmt of piriformis syndrome stretching, ice/heat, PT, meds, injections, electrotherapy, surgery
Percentage of adults w/ bulging discs 50.00%
Percentage of adults under 50 yo with herniated discs 25.00%
After age 50, what happens to disc involvement findings ubiquitous and often asymptomatic
Soonest to do needle EMG 7 days/one week
Reflect neurologic functional status electrodiagnostic studies
How long before needle EMG on peripheral nerve up to 3 weeks before detectable
Needle EMG is also called electromyogram
NYS guidelines for EDX significant radiating extremity sx > 4-6 wks w/ no overt level of nerve root dysfunction
PNCS Peripheral Nerve Conduction Studies
Can substantiate the dix of radiculopathy or spinal stenosis Needle EMG in patients w/ neck pain and/or radiculopathy problems
Can help determine if radiculopathy is acute or chronic Needle EMG
SSEP
EDX that is not for radiculopathy SSEP (myelopathy and intra-operation only)
Myelopathy would cause ____reflexia in lower extremity HYPER
2 electrodiagnostic methods that are never recommended, ever. Surface EMG & CPT
CPT (Current Perception Threshold testing) tells you when they feel it – it's particularly painful. Documents sensory deficit progression
Is an EDX better than MRI? No.
EDX is sensitive, not specific. Explain... Determine site of lesion (sensitive!) but doesn't identify the cause of entrapment (non-specific)
CMAPS and SNAPs Compound Motor Activation Potential & Sensory Nerve Action Potential
CMAPs and SNAPs are motor and sensory ____________ action potentials – stimulate nerve and record response from appropriate mm or nerve
To conduct a motor NCV of wrist, you must cross the entrapment site!
Normal conduction velocity 60 meters/sec
Where will the velocity slow down? Only across the entrapment site, itself
Conduction velocity depends on (4): 1. Internodal distance 2. Age of patient 3. Temperature of patient 4. Myelin thickness
Area between RED lines Amplitude
GREEN line is the start of the action potential …
distance from BLUE line to GREEN line is the latency
X axis measured in milliseconds
Y axis measured in mV
HEIGHT of the evoked response on oscilloscope Amplitude
Measures the time from the stimulus to the onset of the evoked response Latency
Measures the time of the action potential in the negative along x-axis Duration
Increases latency compression of myelin = neuropraxia (can never 'decrease')
Size/height of the response to elec stimulus, or # of conducting fibers Amplitude
There is no myelin loss in neuropraxia (compression of the myelin sheath)
Axonotemesis axonal damage = decrease in amplitude (height/size of response)
Compression causing _________ reduces amplitude. axonal loss
No axonal loss means normal amplitude
Conduction velocity calculated using latency measurements along two different points.
A single latency (CTS) may be significant in evaluating a specific entrapment site
depends on the synchrony b/w fastest and slowest fibers Temporal dispersion
Conduction velocity CAN be affected by Myelin thickness, Internodal distance, Age of Patient, Temperature of patient
Neuropraxia short term compression of myelin sheath
Axonotemesis Axonal loss, nerve sheath intact. Regeneration is possible
Neurotemesis complete severing of nerve
Which degree(s) of compression do not affect amplitude Neuropraxia (intact)
NCV-reduced amplitude, axonal loss, motor weakness, longer recovery Axonotemesis – latency not affected because intact fibers still around to create a.p.
Radic is a _____ lesion. LMNL = radic
Complete division of a nerve, no regeneration, but... Neurotemesis – can get collateral innervation
Axonal loss DISTAL to site of lesion Wallerian degeneration – muscle atrophy b/c of axonal loss distal to lesion
F waves M-wave : motor response due to antidromic activation of peripheral n. when anterior horn cells stimulated
Why is Needle EMG negative with neuropraxia? Must have axonal loss. Early as 7 days for root lesions, late as 3 weeks for peripheral n.
Evoked potentials SSEP – painful. Measure conduction from periphery to cortex. Strictly Sensory! Can use for peripheral nerves or roots.
Which EDX can be used for peripheral nerves or roots Evoked potentials (SSEP) for median, ulnar, radial, etc.
A normal , healthy cell has no electrical activity so only time EMG (+) is when... axonal loss is present.
Needle EMG findings suggestive of ACUTE denervation Fibrillations, (+) Sharp waves, Giant Motor Unit Potentials (MUPs)
Needle EMG is good for detecting both __________ denervation 4 acute and chronic/longstanding axonal loss acute and chronic axonal loss
A needle stuck in a normal motor endplate evokes a ____ response negative. A sharp wave is a (+) response indicating denervation
Can be used to localize peripheral nerve OR root lesions *** EMG – note which muscles show denervation changes
48% of Carpal tunnel syndrome pts have a double crush syndrome
4 states that make nerves susceptible to entrapment *** HypOthyroidism, Pregnancy, Scleroderma, Diabetes
After CTS, what is 2nd most frequent entrapment neuropathy Ulnar neuropathy – Guyon entrapment will spare the volar
A conduction block during EMG for ulnar neuropathy will show 50% decrease in amplitude across the elbow = conduction block
Essential to establish diagnosis of cervical and lumbar radic Needle EMG
Why would denervation of paraspinals demonstrate lumbar radic paraspinals get innervation directly from nerve root – if they are denervated, it's the nerve root lesion
Motor NCV revealed slowing across the elbow Ulnar neuropathy – conduction block across cubital
Neck pain w/ bilateral paresthesias and flick sign. Slowing of Motor and Sensory across wrists. (+) fibs and sharp from paraspinals. Double crush syndrome = CTS and nerve root compression of lower cervical paraspinals show (+) EMG
Martin-Gruber anastamosis connection between median and ulnar nerves (branching)
Dimunition of pulse, hand weakness, atrophy, numbness of arm TOS – brachial plex
Wrist drop after FOOSH 4 weeks ago. Bilateral paresthesias. She has positive Tinels in both wrists. Diagnosis?
(+) fibs and spikes on extensor indices at rest P.I.N. Denervation from entrapment?
Created by: hecutler