spinal disorders pfn: somool08 - jsomtcslides.jsomtc.org/somool08/somool08.pdf · spinal tap (lp)...

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Slide 1JSOMTC, SWMG(A)

Spinal DisordersPFN: SOMOOL08

Hours: 2.5


Terminal Learning Objective

Action: Communicate knowledge of “Spinal Disorders”

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


References

Pathophysiology for the Health Professions, 2011, 4th edition

Merck Manual, 20011, 19th edition

Current Medical Diagnosis & Treatment, 2012, 51st Edition

Special Operations Forces Medical Handbook, 2008 edition

Sanford Guide to Antimicrobial Therapy

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Reason


Agenda

Communicate common disorders of the spine

Communicate referral decisions and red flags

Recall the gross anatomy of the spine and related terminology


Agenda

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of cauda equinasyndrome

Communicate the signs and symptoms, physical exam findings, and management of cervical spondylosis

3


Agenda

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of traumatic cervical spine disorders, to include sprain, radiculopathy, and fractures


Agenda

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of spinal cord shock

Communicate the management of fractures to the thoracic and lumbar spine

Communicate the management of low back pain


Agenda

Communicate the management of lumbar degenerative disk disease and chronic low back pain

Communicate the management of lumbar herniated disk

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of spondylolisthesis

4


Agenda

Communicate the management of acute and chronic infections of the spine

Identify common metabolic causes of back pain

Communicate the relationship between metastatic disease and back pain

Communicate common disorders associated with abnormal curvature of the spine


Common Disorders of the Spine


Common Spine Disorders

Overview

Common causes of back pain

• Strains and sprains

• Degenerative causes

• Herniated disk

• Spondylolisthesis

• Fractures

• Spinal deformities

What else could it be?

5



The diagnostic challenge – red flags

History

Physical exam

Diagnostic tests

Treatment options


History

Start with a good history

•Mechanism of injury

• Historical factors

• Certain qualities of back pain suggest the diagnosis

• Associated symptoms are important!

OPQRST of the pain/duration of symptoms

Any problems with bowel or bladder?




Type of pain/pattern

Location of pain

Deformity

Trauma

Gender

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Conditions by age group

< 10 years:

• Tumor/leukemia

• Kyphosis/scoliosis

11‐19 years:

• Spondylolisthesis; kyphosis

20‐29 years:

• Disk injuries/spinal fracture; spondylolisthesis



30‐39 years:

• Cervical and lumbar disk herniation

• Cervical and lumbar disk degeneration

40‐49 years:

• Cervical and lumbar disk herniation

• Cervical and lumbar disk degeneration

• Spondylolisthesis (degenerative)



50‐59 years:

• Disk degeneration; herniated disk

•Metastatic tumors

> 60 years:

• Spinal stenosis

• Disk degeneration; herniated disk

• Osteoporosis; metastatic tumors

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Physical exam

Inspection

Palpation

Percussion

ROM

Neurovascular examination

Straight leg test



Diagnostic tests

X‐rays

MRI or CT

Laboratory tests

Blood tests

Spinal tap (LP)



Conservative treatment

Analgesia

Muscle relaxant

Therapeutic modalities

Trigger point injections (if trained)

Exercise

Patient education

Surgical consultation

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Referral Decisions and Red Flags


Referral Decisions / Red Flags

Age under 17 or over 55

Violent trauma (e.g., fall from twice height of patient)

Significant nighttime pain or pain @ rest

Bilateral or progressive neurologic deficit

Bowel or bladder control problems


Referral Decisions / Red Flags

PMH – Ca, steroids, HIV or drug abuse

Unwell: fever, chills, unexplained wt. loss

Nerve root pain that is not resolving after 6 weeks

Patients whose symptoms are getting worse despite treatment

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The Gross Anatomy of the Spine and Related Terminology


Anatomy of the Spine



Cervical Spine (7)

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Thoracic Spine (12)



Lumbar Spine (5)


Sacrum/Coccyx (9)


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Intervertebral Disk





Landmarks

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Terminology

Paresthesias – abnormal sensations

Paralysis – loss of sensation, anesthesia, loss of purposefulmovement

Paresis – partial or incomplete paralysis

Paraplegia – paralysis of the lower portion of the body and of both legs

Quadriplegia – paralysis of four extremities

Radiculopathy – irritation of a spinal nerve root; produces pain, weakness, numbness


Terminology

Spondylosis – degenerative arthritis, osteoarthritis, of the cervical or lumbar vertebrae

Spondylolysis – stress fracture, in one of the vertebra (usually @ L5

Spondylolisthesis – weakness in the bone so that it is unable to maintain its proper position and may slip out of place

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The Signs and Symptoms, Physical Exam Findings, Diagnostic Tests, and

Management of Cauda EquinaSyndrome


Cauda Equina Syndrome

Causes – injury to lumbosacral nerve roots


Cauda Equina Syndrome

Signs and symptoms

Motor weakness in the lower extremities

Bowel/bladder dysfunction

Saddle anesthesia

PE: check gait, heel and toe‐walking ability

Treatment/Management

Surgical emergency!

Urgent evacuation

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Management of Cervical Spondylosis


Cervical Spondylosis

Overview

Synonyms

• Cervical arthritis

• Degenerative disk disease of the cervical spine

Degenerative condition of vertebrae/disks

What is the pathology?

Typical patient is > 40 years old


Degenerative Changes


Bilateral Effects Unilateral Effects

Cervical Myelopathy Cervical Radiculopathy

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Clinical symptoms

Stiffness and chronic neck pain

Grinding and popping in the cervical region with motion

Radicular symptoms of pain, weakness, and parethesias occur in one or both upper extremities

Narrowing of the spinal canal and resultant cervical myelopathy seen in older patients





Physical examination

Tenderness along lateral neck or along the spinous processes

Motion may be limited or cause pain

Assess sensory and motor function of the upper extremities (nerve root, positive Spurlingtest)

Evaluate gait as well as bowel and bladder function

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Spurling’s Test (Cervical Compression Test)



Diagnostic tests

X‐rays

CT scans

MRI



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Plan

Conservative therapy

• Anti‐inflammatory drugs

•Muscle relaxants

• Physical Therapy (traction)

Surgery

• If pain is not relieved with 6 months of conservative treatment

• Daily activities become difficult




The Signs and Symptoms, Physical Exam Findings, Diagnostic Tests, and Management of Traumatic Cervical Spine Disorders, to include Strain, Radiculopathy, and Fractures

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Cervical Strain

Overview

Cervical strain/sprain is a common condition that is usually self‐limiting (muscle injury in the neck)

Term is also used to describe ligamentous injuries (neck sprain)

Whiplash mechanism (acceleration‐deceleration of the neck with rapid flexion‐extension)


Cervical Strain

Etiology


Cervical Strain

Clinical symptoms

Nonradicular, nonfocal neck pain is most common

Neck pain relieved with rest/aggravated with activity

Paraspinal muscle spasm, with stiffness and loss of motion

Occipital headache (whiplash injury)

Pain from an acute cervical sprain is usually self‐limiting*

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Cervical Strain


Tenderness in the paraspinous muscles, spinous processes, or interspinous ligaments

Limited motion

The neurologic examination is normal

Diagnostic tests

AP, lateral and odontoid radiographs (or CT) are necessary if Hx of trauma, or associated neurologic deficit, or if patient is elderly

Can also use NEXUS criteria (covered later)


Cervical Strain

Treatment

Provide reassurance about anticipated improvement

Soft collars shown to not help

Appropriate pain medication, and/or short term NSAIDS (avoid narcotics after acute phase)

Muscle relaxants (?)

Aerobic + ROM activities should be started as soon as possible (early mobilization)


Cervical Strain

Whiplash mechanism

Acceleration‐deceleration of the neck with rapid flexion and hyperextension

Patient was an occupant in a car that was suddenly struck in the rear by another automobile

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Cervical Strain

Pearls of management

Is a cervical collar and spine board needed?

X‐rays (NEXUS criteria)

Documentation is important

Delayed recovery related to secondary gain

Therapeutic modalities

Rehabilitation



Management of Cervical Radiculopathy


Cervical Radiculopathy

Herniated Cervical Disk

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Overview

Cause – lateral nerve root entrapment

< 40 y/o is herniation of a cervical disk due to trauma

> 40 y/o is a combination of foraminalnarrowing and degenerative changes to the disk




Clinical symptoms

Neck pain and radicular pain with associated numbness and paresthesias in the upper extremity

Muscle weakness

Occipital headaches

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Cervical lordosis may be reduced

Cervical ROM may be restricted

Extension and axial rotation (Spurling’s test) will often cause pain in the arm and shoulder

Diagnostic tests

Plain radiographs

MRI or CT



Plan

Acute phase – modalities like heat or ice

Immobilization – soft cervical collar

Analgesia – non‐narcotic and muscle relaxants

Physical therapy and exercise

Good PO hydration

Cervical traction in a head halter


The Signs and Symptoms, Physical Exam Findings, Diagnostic Tests, and Management of Cervical Fractures

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Fractures of the Cervical Spine



Overview

Result of high‐energy trauma

Identified or ruled out in all trauma patients who report neck pain, or blows above clavicles

Radiographs are required for all unconscious or intoxicated patients involved in an accident

Generally classified as flexion, extension, compression, or multiple/complex


The key to spinal trauma assessment is “Mechanism of Injury”


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Clinical symptoms

Severe neck pain, paraspinous muscle spasm, and/or point tenderness

Pain that radiates into the shoulder or arm suggests nerve root impingement

Global sensory or motor deficits suggest spinal cord injury

Multiple‐trauma patients: the absence of neck pain does not “clear” a cervical injury

NEXUS criteria (for x‐ray)



Physical exam

Inspect for swelling and contusions

Palpate for tenderness and paraspinal spasm

Evaluate motor, sensory function in both upper and lower extremities

Perianal sensation, sphincter tone, priapism, and bulbocavernosus reflex

Urine retention



Rectal Examination

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Diagnostic tests

X‐rays

• Anterior/posterior, lateral, and odontoid views

• Who needs them?

• Who can be cleared without?

MRI

CT


Fractures of the Cervical Spine First X‐ray of the C‐spine

Cross‐Table Lateral



Reading c‐spine x‐rays

A ‐ Alignment

• Anterior contour line

• Posterior contour line

• Spinolaminal line

• Spinous process tips

B ‐ Bony contour

C ‐ Cartilage/disk

S ‐ Soft tissues

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Cross Table Lateral C‐Spine View




Always evaluate C‐7 and T‐1



Swimmer’s view

If the C‐7 and T‐1 interval is still not well visualized, a "swimmer's view" may be helpful

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AP Cervical Spine View



Odontoid View



Note: Ability to walk, move extremities or feel sensation; or lack of pain to spinal

column does not rule out the possibility of spinal column or cord damage


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Pre‐hospital treatment

When cervical spine injury is suspected?

Cervical spine must be immobilized

• Backboard

• Semirigid collar

Transport to a definitive treatment facility



Plan

The cervical spine must be immobilized during extraction and transport (suspected neck injury), if tactically feasible

Immediate IV steroids?

Definitive care

• Specific injuries involved

• Consult orthopedic or neurosurgeon

• [email protected]



Referral/Red Flags: Patients with fracture, dislocation, subluxation, instability, or neurologic deficit require further evaluation

A high index of suspicion for occult injury should be maintained in the unconscious, intoxicated patient, with an MOI or an unknown MOI

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C‐1 (Jefferson fracture)

Fracture of the C1 ring

Classic 4‐part break of arches



MOI – Vertical compression injury• Weight falling onto the head

• Head striking vehicle roof

• Fall from height onto heels

• Diving accident



Clinical findings

•Minimal to severe pain at the base of the skull

• Limitation of neck motion

• Pain increased in extension

• Damaged spinal cord is uncommon (in living patients)

• Significant cord injury at this level causes immediate death

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C‐2 (Dens fracture)




C‐2 (Dens fracture)

MOI – Multiple or complex

• Combination of flexion, extension and rotation

•Motor vehicle accidents

• Falls

• Sports‐related injuries



Clinical findings

Symptoms can be minimal

Patient may report a feeling of instability at the base of the skull (rare)

Severe pain behind the ears

Patient is seen holding their head with both hands

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In US:• CT of C‐spine is becoming the standard of care

Exception:

• Unstable patient who needs to be intubated, these patients get lateral X‐ray


C‐2 (Hangman’s fracture)




C‐2 (Hangman’s fracture)

MOI – hyperextension and distraction

• Hanging (accidentally or for judicial reasons)

• Striking forehead on car visor/airbags

• Striking chin on steering wheel or dashboard

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Clinical findings

• History of trauma (esp. above clavicle)

• Neck pain

• Neck stiffness

• Tenderness over spinous process of C‐2

• Neck or forehead bruising

• Involvement of the spinal cord in those that survive is rare



X‐rays



C‐7 (Clay‐shoveler fracture)

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C‐7 (Clay‐shoveler fracture)

MOI ‐ hyperflexion

• Hyperflexion avulsion injury

• Sudden muscular contraction

• Hyperflexion, commonly from shoveling snow, although it was originally named for those who were mining clay



Subjective findings• “Knife‐like” pain over C‐7 or T‐1

• MOI involves muscular contraction



Objective findings

Tenderness over the spinous process

Paraspinous muscles are tender

Rule out neurologic deficits

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X‐rays• Lateral x‐ray of the cervical spine

• C7 avulsion fracture



Plan• Symptomatic treatment

• Cervical collar 2‐3 weeks

• MD/PA referral


The Signs and Symptoms, Physical Exam Findings, Diagnostic Tests, and Management of Spinal Cord Shock

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Spinal Cord Shock

Spinal cord injury

Initial injury

Spinal shock

Prognosis

Where is the lesion?


Spinal Cord Shock

Level of functionality

C1‐C3: Quadriplegic, ventilator support

C4‐8: Paraplegic, diaphragm breathing

T1‐12: Paraplegic, normal breathing – (cough reflex impaired)

L1‐S5: Partial paralysis, normal breathing –(cough reflex preserved)


Spinal Cord Shock

Overview

Occurs in 25‐40% of spinal cord injuries

Global neurologic deficits

Systolic hypotension and bradycardia*

Urinary retention

Loss of anal sphincter tone and priapism

Return of bulbocavernosus reflex

Prognosis

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The Management of Fractures to the Thoracic and Lumbar Spine


Thoracic and Lumbar Spine Fractures

Introduction

High‐energy trauma such as motor vehicle accidents or fall from a height

Minor trauma: osteoporosis, tumors, infections

Long‐term steroid use



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Anterior Wedge/Compression fracture




Clinical findings

Moderate‐to‐severe back pain related to a traumatic event

Pain increased with body movement

Numbness, tingling, weakness, bowel and bladder dysfunction suggest nerve root or spinal cord injury



Physical exam

Inspect

Palpate

Evaluate motor/sensory function

Check for neurologic deficits

Evaluate the abdomen and chest

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X‐rays

AP, lateral x‐ray T and L spine

May not be done if suspicion of internal bleed indicates CT needed



Plan (A.B.C.D.E.)

Immobilization (spinal precautions)

Simple compression “wedge” fracture

• Treatment is conservative

• Bed rest and back brace 12‐16 weeks

Unstable fracture/dislocations

• Surgery (internal fixation and spinal fusion)



Red flags

Recent significant trauma any age

Mild trauma over age 50

History of osteoporosis

Prolonged use of corticosteroids

Age greater than 70

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The Management of Low Back Pain


Low Back Pain

Synonyms

Low back pain (LBP)

Pulled low back

Lumbar strain/sprain

History


Low Back Pain

Clinical symptoms

Acute onset of low back pain, often following a lifting episode (may be trivial)

The pain often radiates into the buttocks and posterior thighs; muscle spasms

Patients have difficulty standing erect

Exaggerated responses: generalized hypersensitivity to light touch (or facial grimacing) with minimal loading or movement of spine

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Low Back Pain

Physical exam

Inspection

Diffuse tenderness in the low back

ROM is reduced and elicits pain

The motor and sensory function of the lumbosacral nerve roots and lower extremity reflexes are normal


Low Back Pain

Diagnostic tests

When are plain radiographs needed?

• Infection

• Cancer

• Fractures (and no CT required)

MRI

• Reserved for patients considering surgery

• Cauda equina

• Evidence of a systemic disease

• Not available on emergency basis


Low Back Pain

Treatment

Rest in bed or remain active?

NSAIDs and/or other non‐narcotic pain medications (7‐14 days)

Muscle relaxants may be helpful initially

Avoid narcotic analgesics and sedatives

Reassurance

Patient education

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The Management of Lumbar Degenerative Disk Disease and

Chronic Low Back Pain



Introduction

What is degenerative disk disease (DDD)?

Etiology (physiologic aging)

Chronic, low back pain

Presentation is recurrent and episodic


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Clinical findings

Pain is centered on the lower back, may radiate to hips and legs

Aggravated by activities such as bending, lifting, stooping, or twisting

Relieved with lying down or a night’s rest

Motor, sensory, reflexes normal

Muscle spasm causing a side or forward list



Diagnostic tests

Plain radiographs

MRI



Plan

Chronic pain management problem

NSAIDs and/or other non‐narcotic pain meds*

Reassurance

Weight reduction and daily physical activity

If patient is interested in CAM*, support this

Referral to pain management specialist

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The Management of Lumbar Herniated Disk


Lumbar Herniated Disk

Synonyms

Sciatica

Lumbar radiculopathy



Introduction

Herniated disk syndrome (commonly called “sciatica”)

Mechanism of injury

• Traumatic injury

• Progressive degeneration of the disc

Low back pain that radiates to the leg

Commonly occurs at level L‐4 /L 5, or L‐5/ S‐1

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Subjective findings

O‐onset – when and how did it start? Abrupt or insidious

P‐provocation – exaggerated by sitting, walking, standing, coughing, and sneezing

Q‐quality – sharp or dull, burning, stabbing, numbness or tingling

R‐radiation – unilateral, to the posterior leg

S‐severity – mild to severe

T‐time – history, change in symptoms


Sciatica




Objective findings

Pain exacerbated by bending to affected side (look for “list”)

Restricted ROM

Local tenderness in the sciatic notch

Neurologic examination

Special tests

45


Sciatica



Sciatica



Straight Leg Raise


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Diagnostics

Plain X‐rays demonstrate age appropriate changes

MRI (diagnostic)



Treatment

Limited bed rest, activity as tolerated

NSAIDs and/or non‐opioid analgesics

Muscle relaxants

Narcotics in the acute phase 7‐10 days

Physical Therapy

Epidural corticosteroid injection

Surgery


Surgery (Last)


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The Signs and Symptoms, Physical Exam Findings, Diagnostic Tests, and Management of Spondylolisthesis


Spondylolisthesis


Spondylolisthesis

Introduction

Spondylolisthesis is forward slippage of one vertebra on another

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Types

Degenerative (adult): More common in women over age 40

Isthmic (children): secondary to spondylolysis; more common in athletes (e.g., gymnastics, football, etc.)

Spondylolisthesis



Clinical findings

Pain in the low back, especially after exercising

Increased lordosis (i.e., swayback)

Tight hamstrings

Pain and/or weakness in one or both thighs or legs

Limited straight leg raise

Spondylolisthesis

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Spondylolisthesis

Diagnostics

Lateral x‐ray: forward translation of L‐5 relative to S‐1

Oblique x‐ray: a defect in the pars interarticularis is seen (an absent neck in the “Scotty Dog”)


'Scotty Dog' Sign

Spondylolisthesis


Spondylolisthesis

Spondylolysis Spondylolisthesis

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Spondylolisthesis

Spondylolysis

Presence of a bony defect of the pars interarticularis ‐ may result in spondylolisthesis


Spondylolisthesis


Spondylolisthesis

Plan

Activity restrictions

NSAIDs and/or Tylenol / muscle relaxants

Back brace / physical therapy

Consult

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The Management of Acute and Chronic Infections of the Spine


Osteomyelitis

What is it?

Acute infection:

• Staphylococcus aureus (common)

Chronic infection:

• Tuberculosis (Pott’s Disease)

Symptoms

Diagnosis

Spine Infections


TB of spine – Pott’s disease

Spine Infections

52


Red flags

Persistent fever (temp over 100.4oF)

History of intravenous drug abuse

Recent bacterial infection (GU, cellulitis, pneumonia)

Immunocompromised states (e.g., DM, HIV, etc.)

Night pain, not relieved with rest

Patient usually feels sick

Spine Infections


Spine Infections

Plan

Hospital admit

Antibiotics

• 6 weeks of IV

• 6 weeks oral

Analgesics

Surgery consult


Common Metabolic Causes of Back Pain

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Osteoporosis

Loss of bone mass and density


Osteoporosis

Loss of bone mass density

Risk factors

Complications (Dowager's hump)

Diagnostic screening

Bone mineral density (BMD) test

Treatment ‐ 'CDEF'

Osteoporosis medications


The Relationship Between Metastatic Disease and Back Pain

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Metastatic Disease


Metastatic Disease

Introduction

Malignant tumors involving the spine can be either primary (rare) or metastatic (common)

Pathologic fractures

Etiology


Metastatic Disease

Subjective findings

Back pain: worse at rest; may awaken patient at night

Pain progressively worsens over days and weeks

Weight‐bearing activities aggravate the pain, lying down may relieve it

Back pain severe and not relieved by pain medication

55


Metastatic Disease

Objective findings

Tenderness to palpation or percussion along the spinous processes

Assess motor and sensory function

Check deep tendon reflexes (DTRs)

Evaluation of metastaic cause of tumor


Metastatic Disease

Diagnostics

AP, lateral x‐ray

Bone scan

MRI/CT


Metastatic Disease

Red flags

History of cancer

Unexplained weight loss >10 kg within 6 months

Age over 50 or under 17 years old

Failure to improve with therapy

Pain persists for more than 4‐6 wks

Night pain or pain at rest

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Plan

Immediate consultation

Chemotherapy

Radiation therapy

Surgery

Metastatic Disease


Common Disorders Associated with Abnormal Curvatures of the Spine


Abnormal Curvatures

Scoliosis

57


Abnormal Curvatures

Scoliosis

A lateral curvature of the spine

In adolescence the most common cause is unknown

More common in girls than boys

Changes occur with aging, such as osteoporosis, degenerative disk disease, spinal stenosis, and spondylolisthesis


Abnormal Curvatures

Subjective findings

Pain localized in the region of deformity

Progressive spinal deformity

"getting shorter"


Objective Findings

Abnormal Curvatures

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Abnormal Curvatures

Plan• Non‐operatively

• Stabilization (fusion)


Abnormal Curvatures

Kyphosis

Synonyms

• Postural round back

• Dowager’s hump

• Adolescent kyphosis


Adolescent kyphosis – Scheuermann’s disease

Abnormal Curvatures

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Lordosis

Abnormal Curvatures


Case Study

61 y/o male with CC of “low back pain” x 24h


Case Study

38 y/o male with CC of “back pain that travels down the leg” x 1 wk

60


Case Study

26 y/o male with CC of back pain x 24h


Case Study

66 y/o male with CC of low back pain x 2 wks


Questions?

61


Terminal Learning Objective

Action: Communicate knowledge of “Spinal Disorders”

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


Agenda

Communicate common disorders of the spine

Communicate referral decisions and red flags

Recall the gross anatomy of the spine and related terminology


Agenda

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of cauda equinasyndrome

Communicate the signs and symptoms, physical exam findings, and management of cervical spondylosis

62


Agenda

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of traumatic cervical spine disorders, to include strain, radiculopathy, and fractures


Agenda

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of spinal cord shock

Communicate the management of fractures to the thoracic and lumbar spine

Communicate the management of low back pain


Agenda

Communicate the management of lumbar degenerative disk disease and chronic low back pain

Communicate the management of lumbar herniated disk

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of spondylolisthesis

63


Agenda

Communicate the management of acute and chronic infections of the spine

Identify common metabolic causes of back pain

Communicate the relationship between metastatic disease and back pain

Communicate common disorders associated with abnormal curvature of the spine


Reason


Break

64


Check on Learning

Your team sergeant comes to you with a complaint of back pain x 2 weeks. Which of the following will help you the MOST to make the correct assessment?

A. History

B. Range of motion, looking for limitations

C. X‐rays of the spine

D. Magnetic resonance imaging (MRI)


Check on Learning

Which of the following patients do you feel requires further evaluation?

A. 17‐year‐old taking Motrin as advised for back pain, now complains of pain at rest

B. Soldier who complains of back pain after a hard PLF

C. Injection drug user with back pain and no history of trauma

D. Elderly woman who tripped over her cat complains of moderate back discomfort


Check on Learning

Which part of the spine bears the most weight and as a result is prone to degradation and injury?

A. The first two cervical vertebrae (“Atlas and Axis”)

B. The twelve thoracic vertebrae and ribs

C. The lumbar spine

D. The fused sacrum

65


Check on Learning

Which of the following clinical findings is or are consistent with a cervical radiculopathy?

A. The usual cause in young adults (< 40 y/o) is herniation of a cervical disk

B. May cause painful burning, tingling, or numbness in the neck, shoulder, arm or hand

C. Most cases of cervical radiculopathy resolve in 4‐6 weeks with conservative treatment

D. Many patients state that they can relieve pain by placing the hand of effected side on top of their head


Check on Learning

Which of the following statement(s) is/are true about cervical fractures?

A. Commonly the result of high‐energy trauma

B. Must be identified or ruled out in all trauma patients who report neck pain

C. Radiographs are required for all unconscious or intoxicated patients involved in an accident

D. Generally classified as flexion, extension, compression, or multiple/complex


Check on Learning

Which of the following statements is incorrect about spinal cord shock?

A. Expect hypotension with tachycardia

B. Complete loss of all neurologic function, including reflexes, and rectal tone below level of injury.

C. Spinal shock can last from several days to several weeks

D. Return of bulbocavernosus reflex signifies the end of spinal shock

66


Check on Learning

Preventing neurologic damage is one of the goals of treatment for spinal fracture. How can the medic best accomplish this?

A. Immobilization and spinal precautions during extraction and transport

B. Internal fixation and spinal fusion

C. Steroids should be started immediately

D. Early return to activities as tolerated


Check on Learning

Which of the following choices are consistent with simple low back pain?

A. Acute onset of low back pain without neurologic deficits

B. Night pain that is not relieved with rest

C. Positive smoking history with unexplained weight loss

D. Pain followed post‐traumatic event such as a hard PLF landing


Check on Learning

Which of the following are consistent with degenerative disk disease/chronic low back pain?

A. Age of patient between 30‐50 years old

B. Symptoms are typically recurrent and episodic

C. Symptoms have persisted over 3 months

D. Symptoms are aggravated with activity and alleviated with rest

67


Check on Learning

Which of the following is not consistent with a lumbar radiculopathy “Sciatica”?

A. Typically radiating leg pain is bilateral

B. Herniated disk is most commonly found at the L‐4,5 and L‐5 ‐ S‐1 level

C. Neurologic evidence of irritated S‐1 nerve root is inability to toe walk

D. Clinical findings include a positive straight leg raise test


Check on Learning

Which x‐ray view would be used to show a stress fracture in spondylolysis?

A. Lateral view

B. Anterior‐posterior view

C. Oblique view

D. Inlet‐outlet view


Check on Learning

The usual cause of acute osteomyelitis of the spine?

A. Tuberculosis

B. Gonorrhea

C. Neisseria meningitidis

D. Staphylococcus aureus

68


Check on Learning

Which diagnostic test is the most useful to identify osteoporosis?

A. X‐ray

B. Bone scan

C. Bone mineral density

D. MRI


Check on Learning

The majority of low back complaints will resolve in 1‐4 weeks. Which of the following questions should be asked in a history?

A. Any MOI to suggest fracture

B. Any signs or symptoms to suggest tumor/infection

C. Any bowel/bladder problems or neurologic deficits

D. ROS for referred pain from abdomen or pelvis

spinal disorders pfn: somool08 - jsomtcslides.jsomtc.org/somool08/somool08.pdf · spinal tap (lp)...

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