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NYCC TCH 6705 Loia
NYCC Loia Exam 2 Evi. Based Clin Case Mgmt Sp2012
| Question | Answer |
|---|---|
| #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? |
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hecutler
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