Which organisms are associated with nontuberculous granulomatous spinal infections

Atypical mycobacteria (Actinomyces, Nocardia, and Brucella spp.), as well as fungal infections (coccidioidomycosis, blastomycosis, cryptomycosis, candidiasis, aspergillosis), are potential pathogens. Immunocompromised patients are at high risk for developing infections with atypical mycobacteria. Fungal infections can occur following use of broad-spectrum antibiotics in combination with central venous catheters for parenteral nutrition. Sarcoidosis can involve the spine and cause lytic,...

What are some of the side effects of opioids

Most patients taking opioids experience side effects. The type and intensity of side effects vary greatly. The most common are somnolence and diminished mental acuity. Interestingly, severe pain can itself cause alteration of cognitive abilities and, when opioids relieve pain, cognitive abilities actually improve. Sedation is common, particularly at initiation of treatment or when medication doses are raised, but it usually improves with time. If the opioid is effective, but there is excess...

Describe the presentation of an anterior sacral meningocele

An anterior sacral meningocele is a rare congenital spinal anomaly in which herniation of dura mater and or neural elements through a defect in the ventral spine is identified. The anomaly contains CSF and may contain neural elements. Unlike the myelomeningocele, this anomaly is not associated with hydrocephalus or Chiari malformation. Associated findings include the triad of sacral bony anomalies, a presacral mass, and anorectal anomalies (Currarino syndrome). Symptoms may include...

What is amyotrophic lateral sclerosis ALS

Amyotrophic lateral sclerosis (ALS) is a progressive degenerative disorder of motor neurons in the spinal cord, brainstem, and motor cortex manifested clinically by muscular weakness, atrophy, and corticospinal tract involvement. Clinical presentation typically includes atrophic weakness of hands and forearms, slight spasticity of the legs, and generalized hyperreflexia. Other findings may include hand and finger stiffness, cramping, fasciculations, and atrophy and weakness of tongue,...

What is the tethered cord syndrome

Tethered cord syndrome presents with signs and symptoms that result from excessive tension on the spinal cord. At birth, the conus is usually located at the L2-L3 level and ascends to the L1-L2 level by 3 months of age. Spinal dysraphism is responsible for the majority of cases. A constellation of signs and symptoms is associated with this syndrome including neurologic deficits, back pain, cutaneous abnormalities, spinal deformities, bowel and bladder dysfunction, gait abnormalities, and...

A

Abdominal assessment, after spine fusion, 234 Achondroplastic thoracolumbar kyphosis, 282 Acupressure, 148 Acupuncture, 149 Acute respiratory distress syndrome (ARDS), 232-233 ADA Amendments Act of 2008, 62 Adams test, 53 Addiction, 114 Adolescent idiopathic scoliosis anterior spinal instrumentation and fusion for, 275-276, 276f bracing, use of, 273 characteristic features of, 269 consequences of untreated, 273 evaluation of, 269-270 orthoses, spinal, 143, 143f, 144f pain associated with, 253...

A 70yearold woman complains of increasing low back and upper sacral pain A technetium bone scan was obtained Fig 134

The scan shows increased radionuclide activity above the bladder in the sacral area in a H-shaped pattern (Honda sign). Bilateral increased radionuclide uptake in the sacral ala in association with a transverse region of increased radionuclide activity is typical of a sacral insufficiency fracture, most commonly due to osteoporosis. Figure 13-3. Technetium bone scan demon- Figure 13-4. Increased radionuclide uptake in strates acute two-level osteoporotic compression an H-shaped pattern (Honda...

And Lumbar Spine

Musser, DO, and Richard T. Holt, MD 1. What are the indications for an anterior surgical approach to the thoracic and lumbar spine Anterior spinal decompression and stabilization (e.g. tumor, infection, fracture) Anterior correction of spinal deformity (e.g. scoliosis) To enhance arthrodesis (e.g. for treatment of posterior pseudarthrosis) Anterior release or destabilization to enhance posterior spinal deformity correction (e.g. for treatment of severe, rigid...

Are opioids misused by patients

There are some patients who misuse opioids. Several patterns of misuse have emerged. Perhaps the most serious is drug diversion, obtaining prescription opioids and subsequently selling them. Another serious problem is the use of illegal drugs, such as cocaine or methamphetamine in addition to the opioids. Unsanctioned dose escalation is common and can be due to tolerance, poor pain control, or using opioids to treat psychological or other symptoms. Additional aberrant behaviors include seeking...

Can spinal stenosis occur in the thoracic region

Spinal stenosis can occur in the thoracic region although it is much less common than cervical or lumbar spinal stenosis. Thoracic spinal stenosis occurs most commonly in the T10 to T12 region due to acquired degenerative changes superimposed on preexisting developmental canal narrowing. Hypertrophic spondylosis and ossification of the posterior longitudinal ligament and ligamentum flavum may lead to circumferential narrowing of the lower thoracic spinal canal. A wide range of neurologic...

Compare and contrast the presentation of neurogenic claudication and vascular claudication

Patients with neurogenic claudication report tiredness, heaviness, and discomfort in the lower extremities with ambulation. The distance walked until symptoms begin and the maximum distance that the patient can walk without stopping varies from day to day and even during the same walk. Patients report that leaning forward relieves symptoms. These patients may not experience symptoms during activities performed in a flexed posture such as riding a bicycle or walking uphill. In contrast,...

Define os odontoideum and explain its likely etiology

Os odontoideum is an anomaly of the odontoid process that appears as an ossicle with smooth cortical margins separate from the body of the axis. The atlantoaxial joint becomes unstable as the odontoid becomes unable to function as a peg. Associated symptoms range from mild neck pain to myelopathy and sudden death secondary to minor trauma. Surgery is considered in the presence of neurologic deficit, C1-C2 instability greater than 10 mm on flexion-extension radiographs, or persistent neck pain....

Define pseudarthrosis

Pseudarthrosis is defined as failure to obtain a solid bony union after an attempted spinal fusion. The time between initial surgery and diagnosis of pseudarthrosis is variable. One year following initial surgery is a reasonable and accepted interval for determining fusion success for short segment cervical and lumbar fusions. In certain cases, a patient's symptoms and imaging studies suggest the diagnosis of pseudarthrosis as early as 6 months following initial surgery. However, in patients...

Describe prolotherapy and its use in LBP

Prolotherapy treats back pain that is related to motion and due to weakened or incompetent ligaments and tendons. The injury-repair sequence is initiated by scraping the tissue or adjacent periosteum with a needle and then injecting a dextrose solution to induce fibroblast proliferation and scarring repair of tissue. Prolotherapy can increase tendon size and strength. Success (less pain, less tenderness) in patients with chronic LBP who have not responded to conventional treatment is reported.

Describe the pathogenesis of RA

According to current theories, an unknown antigen triggers the body to produce rheumatoid factor (RF), which is an IgM molecule directed against the Fc portion of immunoglobulin G (IgG). Antigen-activated CD4+ T cells amplify the immune response by stimulating monocytes, macrophages, and synovial fibroblasts to produce the proinflammatory cytokines interleukin-1, interleukin-6, and tumor necrosis factor a (TNF-a), as well as matrix metalloproteinases. Interleukin-1, interleukin-6, and TNF-a are...

Describe the standard radiographic evaluation of a patient with suspected Scheuermanns disease

Standing long cassette posteroanterior (PA) and lateral views of the spine are examined for excessive thoracic kyphosis, vertebral wedging, endplate changes, narrowing of the disc spaces, and scoliosis. The PA view should include the iliac apophyses and triradiate cartilages for evaluation of skeletal maturity. The patient should stand with his or her hips and knees fully extended. The elbows are flexed and the hands supported in the supraclavicular fossa so the arms neither flex nor extend the...

Describe the surgical treatment for flatback syndrome

Fixed sagittal plane imbalance, or flatback syndrome, refers to symptomatic loss of sagittal plane balance primarily through straightening of the normal lumbar lordosis. Symptoms include pain and inability to stand upright with the head centered over the sacrum without bending the knees. Patients typically report a sense of leaning forward, thoracic pain, neck pain, and leg fatigue. Surgical treatment options include osteotomies (Smith-Petersen type or pedicle subtraction type), combined...

Describe the two main types of pulse generators

The two main types of pulse generator systems are totally implantable pulse generators and radiofrequency-driven pulse generators. Totally implantable pulse generators utilize an internal power source (lithium battery). Following activation, these pulse generators are controlled by transcutaneous telemetry and can be switched on-off with a magnet. The battery requires replacement in 2 to 5 years. Despite this disadvantage, totally implantable pulse generators are the most common type of system...

Discuss and contrast the general approach to treatment of intraduralextramedullary spinal cord tumors versus

Intradural-extramedullary spinal cord tumors tend to be histopathologically benign and can be successfully resected in the majority of patients, most commonly through a posterior surgical approach. Tumors in an anterior location and dumbbell-shaped tumors are more challenging to treat surgically. Radiotherapy or chemotherapy is generally reserved for tumors with malignant histologic characteristics and for recurrent tumors. Intramedullary spinal cord tumors are typically treated with open...

Discuss key points to consider in the initial assessment of a patient with AS following a traumatic spinal injury

Spinal pain in the AS patient represents a spinal fracture until proven otherwise. A spine fracture in an AS patient is a high-risk injury with an associated mortality rate reported as high as 30 . These fractures are frequently three-column spinal injuries and are highly unstable due to the long, rigid lever arms created by fused spinal segments proximal and distal to the level of injury. Neurologic injury is common and may be due to initial fracture displacement, subsequent fracture...

Discuss the indications and results of posterior foraminotomy and discectomy for a herniated cervical disc

Patients who have acute radiculopathy without long-standing chronic neck pain and posterolateral or intraforaminal soft tissue disc herniation are excellent candidates for posterior foraminotomies. The disc space height should be well preserved, and there should be no associated spinal instability. The advantages of this technique are avoidance of fusion and early return to function. The disadvantages are difficulty in removing pathology ventral to the nerve root, especially an osteophyte, and...

Explain the differences between T1 and T2weighted MR images

T1 (longitudinal plane relaxation time) and T2 (transverse plane relaxation time) are intrinsic physical properties of tissues. Different tissues have different T1 and T2 properties based on how their hydrogen nuclei respond to radiofrequency pulses during the MR scan. Image contrast of a magnetic resonance imaging (MRI) is determined by varying the scanning parameters (TE and TR). T1 images are produced with a short TR (< 1000 msec) and a short TE (< 30 msec). T1 images are weighted toward...

For which common disorders can a PET scan provide useful diagnostic information

PET scans are most commonly used in the evaluation of cancer for diagnosis, staging, and assessment of treatment effectiveness. Utility in head and neck tumors, colorectal tumors, melanoma, lymphoma, multiple myeloma, lung cancer, and metastatic breast cancer have been reported. The role of PET scans in the diagnosis of spinal infections is evolving. 1. A technetium-99m bone scan can detect regions of increased blood flow or osteoblastic activity. 2. A gallium scan or indium-labeled white blood...

How are postural kyphosis and kyphosis due to Scheuermanns disease distinguished clinically

Postural kyphosis (postural roundback) and Scheuermann's kyphosis are common causes of abnormal sagittal plane alignment in teenagers (Fig. 7-3). They can be distinguished on clinical assessment by performing a forward-bend test and observing the patient from the side. With postural kyphosis, the sagittal contour normalizes because the deformity is flexible. In kyphosis due to Scheuermann's disease, the deformity is rigid (structural) and does not normalize on forward bending. Table 7-1. Causes...

How do I fill out the forms from the SSA

Social Security forms frequently cross a physician's desk. They are often multipaged documents asking many questions. They can be daunting for those who do not understand the process of how the SSA determines disability. The completed forms are intended to provide background information to the impairment and disability evaluator in the Social Security system. An independent impairment examination also may be performed on such patients. The attending physician's report is used to provide...

How does a lumbar disc herniation present in children

Lumbar disc herniation is less common in children than adults. In contrast to adults, children commonly have a history of acute injury or chronic repetitive injury. The child may present with back pain and or radicular leg pain. Physical examination may reveal reduced lumbar range of motion and a positive Lasegue's sign. Neurologic changes and bowel and bladder compromise are rare in adolescents. Initial treatment includes activity reduction, NSAIDs, ice, and physical therapy. Surgery is...

How does an impairment evaluation differ from a normal history and physical examination

Several important differences are seen when these types of examinations are contrasted the goal of the evaluation is different, the patient may be defined differently, and the opportunity for reevaluation is limited in impairment examinations. The goal of an impairment evaluation is to define deviations from normalcy. Having or arriving at a specific diagnosis diagnoses is often useful and helpful. However, a specific diagnosis is not the end result in an impairment evaluation as it is in the...

How does the physician treat a patient with acute LBP

Generally, the offending structure is not known and the natural history is to improve regardless of (or despite) treatment. Few treatments have been proven to be beneficial, but several things may hasten the recovery process. Reassurance is vitally important. Advise the patient that the process is benign and unlikely to lead to long-term impairment, and major intervention is not anticipated. First-line medication options to consider include acetaminophen and nonsteroidal antiinflammatory...

How is DISH different from AS

DISH stands for diffuse idiopathic skeletal hyperostosis. It is also known as Forestier's disease. The disease affects the ligaments along the anterolateral aspect of the spine, which become ossified. DISH typically affects four or more vertebrae, is most common in the thoracic region, and typically spares the lumbar spine and sacroiliac joints. The radiographic hallmark of DISH is the presence of asymmetric nonmarginal syndesmophytes, which appear as flowing anterior ossification originating...

How is muscle energy manipulation performed When is it useful

Muscle energy manipulation requires that the patient perform a voluntary contraction of muscle in a specific direction, at increasing levels of intensity, against a counterforce applied by the practitioner. For a specific segmental dysfunction, the patient is passively moved to the pathologic barrier to motion and then asked to move away from the barrier with gentle muscle contractions of a 3- to 5-second duration. This action is thought to relax the muscle involved in moving the joint toward...

How is RA diagnosed

A comprehensive history and physical examination is performed. RA is a symmetrical, erosive polyarthritis of small and large joints along with involvement of the axial skeleton. The patient will complain of significant morning stiffness. Rheumatoid nodules are common. Neck pain may or may not be present. Cervical radiographs are characterized by AAS, facet joint erosions without sclerosis, and disc space narrowing without osteophyte formation. Characteristic laboratory abnormalities include...

How is spinal impairment evaluated

The practitioner can evaluate spinal impairment by quantifying spinal range of motion, assessing trunk strength and endurance, evaluating balance and motor control, and determining aerobic fitness. Techniques for measuring spinal range of motion include inclinometer, goniometer, modified Schober test, and finger-to-floor distance. There are three basic approaches for testing trunk extensor strength and lifting capacity isometric (velocity is zero), isokinetic (velocity is constant), and...

How is the F wave elicited What is its value in the assessment of radiculopathy

The F wave is a compound action potential evoked from a muscle by a supramaximal electric stimulus to its related peripheral nerve. This procedure results in an antidromic activation of the motor neuron. The F wave has variable configuration, latency, and amplitudes. Amplitudes generally range between 1 and 5 of the M wave. F waves are abnormal immediately after nerve root injury, even when the needle EMG is normal. However, an F-wave study has low utility for diagnosing a radiculopathy because...

How is the halo skeletal fixator applied

The patient is placed supine with the head position controlled by the physician in charge (Fig. 18-10). The correct ring size (permits 1-2 cm of circumferential clearance around the skull) and vest size are determined. Critical measurement to determine correct vest size include 2. Chest circumference at level of xiphoid 3. Distance from shoulder to iliac crest Pin sites are identified. The skin is cleaned with Betadine, and pin sites are injected with 1 lidocaine. The patient is instructed to...

In addition to Harrington instrumentation what are some other causes of sagittal imbalance syndrome

Sagittal imbalance syndrome may occur for many reasons in addition to Harrington instrumentation for scoliosis treatment. Sagittal plane malalignment may occur after lumbar fusion for degenerative spinal disorders when adequate lumbar lordosis is not restored during the initial surgery. Transition syndrome (breakdown of spinal segments above or below a solid spinal fusion) is another frequent cause of sagittal imbalance. Autofusion of the spine as a result of Forestier's disease (diffuse...

Ito The Thoracic And Lumbar Spine

Describe the options for patient positioning for posterior surgical approaches to the thoracic and lumbar spinal regions. Typically patients are positioned prone on a radiolucent operative frame for posterior approaches to the thoracic and lumbar spine. An exception is the use of a lateral decubitus position during simultaneous anterior and posterior surgical procedures. 2. What are the basic types of positioning frames for posterior spinal procedures Four-post frame Proximal pads are placed...

Outline a treatment plan for patients with thoracic radiculopathy

Thoracic radiculopathy may be due to disc herniation or metabolic abnormalities of the nerve root (i.e. diabetes). Patients present with bandlike chest pain. Thoracic radiculopathy is not a common diagnosis, and other possible serious pathology should be excluded (malignancy, compression fracture, infection, angina, aortic aneurysm, peptic ulcer disease). Nonsurgical treatment options for thoracic radiculopathy include medication (NSAIDs, analgesics, oral steroids), modalities, TENS, spinal...

Vincent J Devlin MD and Darren L Bergey MD

Describe the bony landmarks of the occiput. The occiput forms the posterior osseous covering for the cerebellum. The foramen magnum is the opening through which the spinal cord joins the brainstem. The anterior border of the foramen magnum is termed the basion (clivus), and the posterior border is termed the opisthion. The inion or external occipital protuberance is the midline region of the occiput where bone is greatest in thickness. The superior and inferior nuchal lines extend laterally...

What anatomic structures should be routinely assessed on an MR study of the lumbar spine

Normal cervical spine anatomy. The sagittal T1 -weighted image (A) provides excellent anatomic delineation of the vertebral bodies (curved black arrows), intervertebral discs (straight black arrows), and spinal cord (white arrows). On the sagittal cardiac gated T2-weighted image (B), a myelographic effect is created by the increased signal intensity in the cerebrospinal fluid (CSF). There is an excellent interface between the posterior margin of the discovertebral joints (curved...

What are flexion exercises Williams exercises When are they appropriate

Examples of flexion exercises include knee-to-chest exercises (Fig. 14-1), abdominal crunches, and hip flexor stretches. Flexion exercises are commonly prescribed for facet joint pain, lumbar spinal stenosis, spondylolysis, and spondylolisthesis. Flexion exercises increase intradiscal pressure and are contraindicated in the presence of an acute disc herniation. Flexion exercises are also contraindicated in thoracic and lumbar compression fractures and osteoporotic patients. Flexion exercises...

What are important points to assess on physical examination in the patient being evaluated for possible revision spine

A general neurologic assessment and regional spinal assessment are performed. The presence of nonorganic signs (Waddell signs) should be assessed. Global spinal balance in the sagittal and coronal planes should be assessed. The physical examination is tailored to the particular spinal pathology under evaluation. For cervical spine disorders, shoulder pathology, brachial plexus disorders, and conditions involving the peripheral nerves should not be overlooked. For lumbar spine problems, the hip...

What are nerve root tension signs

Tension signs are maneuvers that tighten the sciatic or femoral nerve and in doing so further compress an inflamed nerve root against a lumbar disc herniation. The supine straight leg raise test (Lasegue's test) and its variants (sitting straight leg raise test, bowstring test, contralateral straight leg raise test) increase tension along the sciatic nerve and are used to assess the L5 and S1 nerve roots. The femoral nerve stretch test (reverse straight leg raise test) increases tension along...

What are some emerging techniques for treatment of osteoporotic fractures

Investigational techniques include use of bioactive cements and implantation of devices in combination with PMMA into the fractured vertebral body. Hybrid surgical procedures have been reported that combine vertebral body augmentation procedures with traditional open surgical techniques. In patients with spondylolisthesis or kyphotic deformity, posterior pedicle screw-rod fixation has been performed in combination with posterior surgical decompression and cement augmentation. Although...

What are spinal stabilization exercises When are they used

Strengthening exercises for a dynamic corset of muscle control to maintain a neutral position are known as spinal stabilization exercises. Recently, there has been a special focus on the role of the transversus abdominis and lumbar multifidi muscles in enhancing spinal stability. The goal of stabilization exercises is to reduce mechanical stress on the spine. Spinal stabilization exercises can be prescribed for most causes of low back pain. Key concepts of spinal stabilization exercise program...

What are the basic components of an electrodiagnostic examination

EDX is an extension of the history and physical examination. Its goal is to help in distinguishing among the variety of causes for numbness, weakness, and pain. The standard EDX examination consists of two parts electromyography (EMG) and nerve conduction studies (NCS). EMG (needle electrode examination) uses a needle antenna to detect and record electrical activity directly from a muscle. The four standard components of the examination assess The distribution of abnormalities identifies the...

What are the different types of basilar impression

There are two main types of basilar impression primary and secondary. The primary type is most common. It is frequently associated with other vertebral defects, including atlanto-occipital fusion, odontoid abnormalities, Klippel-Feil anomaly, and hypoplasia of the atlas. Vertebral artery abnormalities may also be present. Secondary basilar impression arises as the result of softening of osseous structures at the base of the skull. Diseases associated with secondary basilar impression include...

What are the indications for surgical treatment for a lumbar disc herniation

Occasionally an acute massive disc herniation can result in cauda equina syndrome, which is best managed by emergent surgical treatment. However, most patients undergo elective surgical treatment due to failure of radicular pain to improve with nonsurgical treatment. Surgical treatment is directed at improving the patient's leg pain. When the predominant symptom is back pain, symptom relief is unpredictable, and discectomy is not advised. Appropriate criteria for surgical intervention include...

What are the limitations of DEXA scans for predicting fracture risk

DEXA scans do not convey all the necessary information to predict a specific patient's fracture risk. This is highlighted by the finding that up to half of all osteoporotic-related fractures occur in patients with BMD values classified as osteopenia. Thus, factors in addition to BMD require consideration in the assessment of fracture risk. The FRAX tool (http www.sheffield.ac.uk FRAX ) has been developed by the World Health Organization to integrate important clinical risk factors and bone...

What are the most common presenting symptoms of spinal tumors

Pain is the most common presenting symptom. Pain is frequently described as persistent, progressive, and not typically associated with activity. Pain at night is a characteristic symptom. Subjective weakness, radiculopathy, objective neurologic deficit, and bladder or bowel dysfunction may develop over time. Other presenting symptoms include a palpable mass or painful spinal deformities. Pelvic girdle malignancies, including chordoma, osteosarcoma, chondrosarcoma, and malignant fibrous...

What are the most common types of extradural spinal tumors

Extradural tumors (Fig. 62-2) may be primary tumors originating from the vertebra and adjacent soft tissues or develop secondary to metastatic disease. The most common extradural spinal tumor is a metastatic tumor. The most common primary bone tumor is multiple myeloma. The differential diagnosis of an extradural spinal tumor is listed in Table 62-1. Figure 62-2. Extradural spinal tumor. Magnetic resonance imaging (MRI) of primary osteosarcoma in lumbar spine. A, Low to intermediate signal...

What are the surgical treatment options for SAS

Anterior decompression (discectomy or corpectomy) and arthrodesis with anterior plate fixation. However, anterior grafts are prone to subsidence and pseudarthrosis, and anterior screw purchase is often poor. Concomitant posterior fixation should be strongly considered Posterior cervical arthrodesis with screw-rod fixation 1. Three types of cervical deformities develop secondary to rheumatoid disease atlantoaxial subluxation (AAS), atlantoaxial impaction (AAI), and subaxial subluxation (SAS)....

What are the three most frequent routes by which bacterial infection spreads to the spinal column

The most common method for bacteria to spread to the spine is by the hematogenous route. Common sources of infection include infected catheters, urinary tract infection, dental caries, intravenous drug use, and skin infections. The second most common route is local extension from an adjacent soft tissue infection or paravertebral abscess. The third most common route is direct inoculation via trauma, puncture, or following spine surgery. The nucleus pulposus is relatively avascular, providing...

What are the types of chronic spine pain

Chronic spine pain can be subdivided into nociceptive and neuropathic types. Nociceptive pain is due to a structural disorder that stimulates small nerve endings (nociceptors). An example is a patient with one or more painful degenerated discs. Neuropathic pain is due to permanent nerve damage or physiologic change to the peripheral or central nervous system. The nerve is the source of the pain even though it is no longer being stimulated. Neuropathic nerves may have a lowered threshold for...

What complications have been reported in association with microsurgical lumbar discectomy

Fortunately complications are rare but may include Vascular injury Nerve root injury Dural tear Infection Recurrent disc herniation Cauda equina syndrome Medical complications (e.g. thrombophlebitis, urinary tract infection) windows of opportunity into the spinal canal interlaminar (right) and intertransverse (left). (From McCullough JA. The lateral approach to the lumbar spine. Oper Tech Orthop 1991 1 27, 55, with permission.) windows of opportunity into the spinal canal interlaminar (right)...

What elements of the patients history are most important

The patient's medical history is vital and should be comprehensive. Determine the onset and duration of the problem the reason it occurred (if any) its relation to work, automobile, or other injury if litigation is involved and if there is financial remuneration. Define the pain carefully its location, relationship to position and activity, and time of day it is most prominent. Determine if there are associated symptoms such as pain in an extremity, numbness, or tingling. Red flags that may...

What features suggest that torticollis is due to atlantoaxial rotatory subluxation

Features that suggest that torticollis is due to atlantoaxial rotatory subluxation include prior normal cervical alignment and motion, history of recent upper respiratory infection (Grisel's syndrome), normal neurologic examination, and spasm in the sternocleidomastoid muscle on the side opposite the head tilt. This posture has been termed the cock robin deformity. It is distinct from congenital muscular torticollis, in which muscle spasm occurs on the same side as the head tilt. Plain...

What if the pain persists for several weeks after the initial treatment

If the pain still does not resolve, the patient should be provided with reassurance. If not already performed, imaging studies are appropriate. MRI should be interpreted cautiously and correlated with clinical findings. If serious spinal pathology requiring referral to a spine specialist is not identified, supportive treatment is continued. Determine the severity of pain perception and how it interferes physically, psychosocially, and psycho-emotionally with function. Treatment options at this...

What initial treatment is advised for patients with a suspected acute lumbar disc herniation

Initial treatment options include a short period of bedrest (not to exceed 3 days), oral medications (nonsteroidal antiinflammatory drugs NSAIDs , aspirin, mild opioids), progressive ambulation, return to activity, and patient reassurance. Epidural injections can be considered. As acute pain subsides, physical therapy and aerobic conditioning are advised. If a patient fails to improve with 4 to 6 weeks of nonsurgical care, further evaluation is indicated. The optimal time for nonsurgical...

What is apportionment

Apportionment refers to a division of responsibility. Apportionment can be applied to the impairment rating based on causative factors. For example, if a worker applies for disability benefits because of a toxic gas inhalation, some states take into consideration the fact that this person was a two-pack a day smoker for the past 20 years. The final amount of the loss of lung function is thus apportioned into the various contributing causative factors. Apportionment can also refer to the...

What is peak bone mass PBM

Peak bone mass (PBM) is defined as the highest level of bone mass achieved as a result of normal growth. Bone mineral density (BMD) increases rapidly during adolescence until PBM is reached between 16 and 25 years of age. After age 30, men normally lose bone at a rate of 0.3 per year. After age 30, women normally lose bone at a rate of 0.5 per year until menopause, at which time the rate of bone loss accelerates to 2 to 3 per year over a 6- to 10-year period. The greater the PBM, the better the...

What is sagittal imbalance syndrome What are the most common causes

Sagittal Imbalance syndrome is a disabling postural disorder characterized by low back pain, forward inclination of the trunk, and difficulty in maintaining an erect posture. The patient attempts to compensate for this abnormal posture by either hyperextending the hips or standing with the hips and knees flexed. This syndrome results from decreased lumbar lordosis with subsequent global imbalance in the sagittal plane. The disorder was initially termed flatback syndrome and described in...

What is SEP testing What is its value in the investigation of radiculopathy

SEPs are waveforms recorded over the scalp or spine following electrical stimulation of a mixed or sensory nerve in the periphery. SEPs are conducted in the posterior columns of the spinal cord, which represent nerve fibers carrying joint position and vibratory sensation. These nerve fibers usually remain unaffected in radiculopathy. SEPs are used successfully in monitoring spinal cord function during spinal surgery, and prolonged SEP latency can be the earliest sign in extensive multiroot...

What is Social Security Disability SSD

According to the Social Security Administration (SSA), disability is defined as the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. In addition, for a person under the age of 18, disability can exist if he or she has a medically determinable impairment(s) that is of comparable...

What is the Arnold Chiari malformation

The Arnold-Chiari malformation is a developmental anomaly in which the brainstem and cerebellum are displaced caudally into the spinal canal. In Type 1 Arnold-Chiari malformation, the cerebellar tonsils are displaced into the cervical spinal canal. This malformation is associated with other cervical anomalies including basilar impression and Klippel-Feil syndrome. Dense scarring at the level of the foramen magnum may lead to hydromyelia or syringomyelia. Type 2 Arnold-Chiari malformation is a...

What is the difference between discitis and vertebral osteomyelitis

In the past, a distinction was made between discitis (infection involving the disc space) and osteomyelitis (infection in the vertebral body). Studies have shown that in children the vascular supply crosses the vertebral endplate from vertebral body to the disc space. As a result, discitis and vertebral osteomyelitis are considered to represent a continuum termed infectious spondylitis. Hematogenous seeding of the vertebral endplate leads to direct spread of infection into the disc space....

What is the incidence of osteoporotic vertebral compression fractures

Vertebral compression fractures are the most common fractures due to osteoporosis. Vertebral fractures are two to three times more prevalent than hip fractures or wrist fractures. The exact incidence of osteoporotic vertebral compression fractures is difficult to estimate but is quite high. In the United States alone, osteoporotic vertebral compression fractures are estimated to affect 200,000 to 700,000 persons per year. The difficulty estimating incidence arises because many people have a...

What is the management for a newborn patient with myelomeningocele

Upon birth, the baby should be placed prone and the lesion covered with moist nonadherent dressing (Telfa). Trendelenburg position may prevent CSF accumulation at the lesion site. If the lesion is open and CSF leakage is noted, prophylactic antibiotics to prevent meningitis are administered. Careful neurologic examination is documented prior to surgery. Surgical closure should be performed within 48 to 72 hours of birth but may be delayed a week to allow for parental discussion regarding...

What is the most common pyogenic organism responsible for osteomyelitis involving the spine

Staphylococcus aureus is the most common organism and has been identified in over 50 of cases. However, infections due to a diverse group of gram-positive, gram-negative, and mixed pathogens may occur. Gram-negative organisms (Escherichia coll, Pseudomonas spp., Proteus spp.) are associated with spinal infections following genitourinary infections or procedures. Intravenous drug abusers have a high incidence of Pseudomonas infections. Anaerobic infections are common in diabetics and following...

What is the most common type of torticollis

Congenital muscular torticollis is the most common type of torticollis. It presents in the newborn period. Its cause is unknown, but it has been hypothesized to arise from compression of the soft tissues of the neck during delivery, resulting in a compartment syndrome. Radiographs of the cervical spine should be obtained to rule out congenital vertebral anomalies. Clinical examination reveals spasm of the sternocleidomastoid muscle on the same side as the tilt causing the typical posture of...

What is the role of orthotic treatment

The role of orthotic treatment is two fold (1) to help nonambulatory patients to sit with the use of a seating support, and (2) to attempt to control spinal deformity. In most cases of neuromuscular scoliosis, a spinal orthosis will not prevent curve progression. However, orthotic treatment is valuable in slowing progression of spinal deformities until the onset of puberty and permits growth of the spine prior to definitive treatment with spinal instrumentation and fusion. Orthotic management...

What is the significance of a painfree interval following a spinal decompression procedure

The presence or absence of a pain-free interval following a spinal decompression procedure (e.g. lumbar laminectomy) can provide a starting point for determining the most likely causes of persistent symptoms When the patient has no immediate relief, the wrong operation or wrong diagnosis should be suspected When the patient has immediate relief but symptoms recur within weeks to months after the operation, new pathology or a complication of the initial operation should be suspected When the...

What is the typical history of a patient with a lumbar disc herniation

Typically there is an attempt to link the onset of back and leg pain with a traumatic event, but frequently patients have experienced intermittent episodes of back and leg pain for months or years. Factors that tend to exacerbate symptoms include physical exertion, repetitive bending, torsion, and heavy lifting. Pain typically begins in the lumbar area and radiates to the sacroiliac and buttock regions. Radicular pain typically extends below the knee in the distribution of the involved nerve...

What mechanical factors have been associated with disc degeneration

Disc degeneration has traditionally been linked to mechanical factors such as excessive or repetitive loading resulting in structural injury and subsequent development of axial pain symptoms. Factors traditionally associated with the occurrence of disc degeneration according to this injury model include age, occupation, male gender, cigarette smoking, and exposure to vehicular vibration. An observation cited to support a mechanical basis for disc degeneration is the development of degenerative...

What procedure is indicated to treat congenital lumbar kyphosis in a child with spina bifida

Indications to resect a kyphosis include skin breakdown over the kyphosis and inability of the child to use their hands due to the need to support himself or herself on the thighs. The procedure includes resection of vertebrae in the region of the apex of the deformity, segmental fixation to any remaining posterior bony structures, and placement of S-shaped rods inserted distally through the L5-S1 neural foramen. This technique involves placement of a rod with two 90 bends at the...

What questions should be considered before ordering a CTmyelogram study of the spine

Can the pertinent clinical question be answered with noninvasive diagnostic imaging, such as MRI or a combination of MRI and CT 2. Will the information obtained from the study have an important impact on clinical management of the patient 3. Does the patient have any history of adverse reaction to iodinated contrast media or any conditions that increase the risk of an adverse reaction to these agents Some factors considered to increase the risk of a reaction to iodinated contrast include renal...

What radiographic hallmarks indicate a flatback syndrome

Flatback syndrome is a sagittal malalignment syndrome. Radiographically the hallmarks of flatback syndrome include a markedly positive sagittal vertical axis and decreased lumbar lordosis after a spinal fusion procedure. Classically, it has been reported after use of a straight Harrington distraction rod to correct a lumbar or thoracolumbar curvature. When the thoracic and lumbar spine is fused in a nonphysiologic alignment with loss of lumbar lordosis, the patient cannot assume normal erect...

What special considerations should be given to patient positioning and anesthesia for cervical osteotomy procedures in

The operation is carried out under local anesthesia, with the patient awake in the sitting position using a dental chair. This protocol allows active spinal cord monitoring and immediate assessment of vital functions and neurologic status. Intravenous sedation may be used in conjunction with local anesthesia. Routine monitoring of vital signs, pulse oximetry, carbon dioxide, and systemic blood gases is performed. A Doppler device is fixed to the patient's chest to detect air embolism. The...

What surgical procedure is recommended for treatment of a symptomatic lumbar disc herniation

Open lumbar discectomy using microsurgical technique remains the gold standard for the treatment of a symptomatic lumbar disc herniation (Fig. 49-3). Important technical points include use of a small incision, limited muscle and bone dissection, and limited removal of displaced or loose disc material. A surgical microscope or headlight and loupe magnification is used to enhance intraoperative visualization. Uncomplicated patients typically go home within 24 hours of surgery and are able to...

What types of adverse reactions can occur during a CTmyelogram procedure

Initially patients may experience discomfort during intrathecal injection of the nonionic water soluble contrast agent. After injection, patients may experience an anaphylactoid (idiosyncratic) reaction (urticaria, facial and laryngeal edema, bronchospasm, hypotension) or a nonidiosyncratic reaction due to the adverse effect of contrast on a specific organ system (nephrotoxicity, cardiac arrhythmia, myocardial ischemia, vasovagal reaction). Specific treatment depends on the exact clinical...

When a patient undergoes a spinal decompression procedure and reports temporary relief of symptoms followed by

Recurrent spinal stenosis and spinal instability. Recurrent spinal stenosis commonly presents as lateral stenosis secondary to disc space collapse after a discectomy. Risk factors for instability after lumbar decompression procedures include recurrent disc surgery at the L4-L5 level, multilevel decompression in patients with osteoporosis, and multilevel decompression in patients with scoliosis, especially if the deformity is flexible based on preoperative bending radiographs (Table 34-1).

When are children with spondylolysis and spondylolisthesis referred to the spine specialist for evaluation

The presentation of patients with spondylolysis and spondylolisthesis is varied. Symptomatic patients most commonly present with low back pain, which may radiate into the buttocks and thighs. Hamstring tightness or spasm is not uncommon. Some patients will recall an episode of inciting trauma. Occasionally a patient will report radicular symptoms due to nerve compression at the level of the slippage. Patients with severe degrees of spondylolisthesis may present with postural deformity,...

When are COs prescribed How do they work What are the commonly used types of COs

COs are commonly prescribed for pain associated with cervical spondylosis, for stabilization following cervical spinal surgery, and for protection and immobilization of the cervical spine following trauma. COs are cylindrical in design and encircle the neck region. They may be anchored to the mandible and or the occiput to increase stiffness and motion control. COs may be soft or rigid. Soft collars provide no meaningful motion control. Rigid COs (e.g. Philadelphia, Miami-J) restrict...

When is the use of longterm opioids considered appropriate in the management of spinal disorders

Long-term opioids are appropriate for spine patients with a well-defined structural stimulus that cannot be definitively treated. The pain level should be consistent with the structural disorder present in the spinal column. Aggressive rehabilitation and other appropriate interventions should be pursued, and their failure to relieve pain should be documented. There should be no significant psychological illness or history of addiction or drug abuse. Opioids should not be used to treat...

When should I order a spine radiograph

Plain radiographs should be the initial imaging study of the spine. Because of the favorable natural history of acute cervical and lumbar pain syndromes, it is not necessary to order initial spine radiographs for every patient who presents with neck or low back pain. Indications for obtaining spine radiographs in patients presenting with cervical, thoracic, or lumbar pain include Patients younger than 20 years or patients older than 50 years Patients who fail to respond to conservative...

Who is at greatest risk of developing an osteoporotic vertebral compression fracture

The biggest risk factor for having a vertebral compression fracture is a prior osteoporotic fracture. A person who suffers a vertebral fracture is five times more likely to suffer an additional fracture, when compared with a control with no fracture. Because osteoporosis disproportionately affects older persons, age is a risk factor. In a large cohort of middle-aged individuals studied with serial radiographs over 2 decades, 24 of the women and 10 of the men sustained a vertebral fracture over...

Who wrote the rules for impairment evaluation

Disability is a big business in the United States and other countries. Various institutions pay the costs, such as state governments (workers' compensation), the federal government (e.g. for veterans or longshoremen), insurance companies, and self-insured employers. Many systems that pay for disability have their own rules and regulations, including rules about the performance and rating of the impairment. The most commonly used system is a formal set of rules developed by the American Medical...

Which anticonvulsant is most commonly used for neuropathic pain

Gabapentin (Neurontin) is currently used most often, although its use for pain is off-label. It may be useful for neuropathic extremity pain due to iatrogenic nerve injury, arachnoiditis, prolonged neural compression, and peripheral neuropathy. It has been shown to be useful in some patients with leg pain due to spinal stenosis. Gabapentin is started at 100 to 300 mg at night and then increased to 300 mg every 8 hours over the days to weeks, and then gradually titrated upward until there is...

When are antidepressants useful for patients with spine problems

Antidepressants have several potential uses in patients with chronic spinal problems, including the treatment of back pain, neuropathic pain, sleep disturbance, and depression. Only the antidepressants with primarily nonadrenergic activity are useful for pain. The data regarding efficacy of antidepressants for axial pain are equivocal. At best, isolated studies show about 30 reduction in pain in one third of patients. In addition, recent data suggest these drugs are not very effective for...

What is rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder of uncertain etiology. It is an immunologically mediated systemic disorder that affects articular and nonarticular organ systems. The articular involvement is a symmetrical peripheral joint disease affecting large and small joints. Axial involvement predominantly affects the cervical region, especially the upper cervical spine. The extra-articular involvement may affect the skin, eyes, and larynx, as well as the pulmonary,...

What problems have been associated with the use of halo orthosis

Complications associated with use of a halo orthosis include pin-loosening, pin-site infection, discomfort secondary to pins, scars after pin removal, nerve injury, dysphagia, pin-site bleeding, dural puncture (following trauma to the halo ring), pressure sores secondary to vest irritation, reduced vital capacity, brain abscess, and psychological trauma. Although the halo is the most restrictive of the various CTOs, significant motion may occur due in part to difficulty in fitting the brace...

Describe the prevalence and natural history of lumbar disc herniations How do they differ from the prevalence and

The lifetime prevalence of a lumbar disc herniation is approximately 2 . The natural history of sciatica secondary to lumbar disc herniation is spontaneous improvement in the majority of cases. Among patients with radiculopathy secondary to lumbar disc herniation, approximately 10 to 25 (0.5 of the population) experience persistent symptoms. These statistics are in sharp contrast to low back pain, which has a lifetime prevalence of 60 to 80 in the adult population. Although the natural history...

What is the incidence of recurrent disc herniation after microsurgical lumbar discectomy

The incidence of recurrent disc herniation following microsurgical lumbar discectomy is 5 to 10 . Higher rates of recurrence (up to 26 ) have been reported in patients in whom large annular defects were present at conclusion of discectomy. If symptoms are predominantly radicular in nature, repeat lumbar discectomy may be beneficial. If symptoms include a combination of radiculopathy and low back pain, discectomy combined with fusion may be considered in select patients with recurrent lumbar...

What is the role of chemotherapy in the treatment of a metastatic spinal lesion

Chemotherapy is used in patients with documented spinal metastases, patients at risk of developing spinal metastases, and patients with spinal lesions not amenable to surgical excision. The response to chemotherapy is determined by the tumor type. Tumors that are highly sensitive to chemotherapy include small-cell carcinoma of the lung, Ewing's sarcoma, thyroid carcinoma, breast carcinoma, lymphoma, germ cell tumors, and neuroblastoma. Tumors that are relatively resistant to chemotherapy...

Describe herbal therapy

Herbal medicine is most often associated with traditional Chinese medicine, Indian traditional medicine (Ayurveda), or Western herbalism. It is a form of botanical medicine that uses plant extracts to treat various diseases. Patients should be aware that herbal therapies are not without potential for adverse interactions with other medications. In addition, herbal remedies are not regulated by the Food and Drug administration (FDA). Two herbs commonly used to treat LBP are arnica and St. John's...

Describe the clinical features of spina bifida occulta

In spina bifida occulta the underlying spinal and or neural defect is covered by intact skin and thus may not be grossly evident on examination. External signs may include a lumbosacral hair tuft (faun's tail), skin-covered lipoma, cutaneous hemangioma, or a lumbosacral skin dimple. If the defect is limited to failure of fusion of the vertebral arch, the finding has little clinical significance. However, more complex types are associated with neurologic, urologic, and or orthopaedic...

What is a lipomyelomeningocele

A lipomyelomeningocele is a common congenital spinal anomaly in which herniation of a lipoma into the conus medullaris or the dorsal spinal cord occurs through an osseous defect and communicates with an adjacent subcutaneous fatty mass. It is a common cause of tethered cord syndrome. Symptoms may include constipation, urinary urgency, dyspareunia, lumbar pain, or cephalgia (headache) with defecation. The term lipomyelomeningocele is actually a misnomer, because abnormal neural tissue does not...

What guidelines exist to aid the practitioner in pursuing an effective and systematic approach to the child with back

An algorithm has been developed to guide patient assessment on data obtained from clinical history and physical examination (Figure 36-1). The algorithm takes into account three factors 1. Mechanism of injury Clear or unclear 2. Nature of symptoms physical findings Local vs. systemic vs. neurologic 3. Duration of symptoms Less than 1 month vs. greater than 1 month The patient may enter into the algorithm at any stage on findings noted in the history and physical examination. The patient may...

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Complementary and alternative medicine treatments, 146-150 as indication for spinal surgery, 153 low assessment and management, 329-331 cardiovascular conditioning, role of, 108-109 common causes of lumbar pain, 106 complementary and alternative medicine treatments for, 146-150 discogenic, 337-341 lumbar spine exam, 41-44 in lumbar spine injuries in athletes, 417 orthosis for, 144 probability of recovery, changes in, 106 treatment plan for, 106 trunk strength deficits and, 110 pediatric,...

Which patients are less than ideal candidates for surgical treatment for lumbar DDD

Surgical treatment is associated with poor outcomes in patients with unresolved secondary gain issues, worker's compensation claims, litigation, multiple emergency department visits, high levels of opioid usage, abnormal psychometrics, chronic pain illness, and exaggerated pain behaviors. Patients off work greater than 3 months tend to have worse results. To have any sense that surgery might benefit the patient, the surgeon must get to know the patient. Overreliance on MRI or discography data...

What is the most important component of an exercise program for the treatment of low back pain due to lumbar DDD

The most important component of a low back exercise program is to address fear-avoidance behavior of the patient by reassuring the patient that it is safe to exercise despite the chronic pain he or she may experience. The appropriate exercise program is a supervised active physical therapy program that uses progressive, non-pain contingent exercise (i.e. the patient is encouraged to exercise despite their pain) to increase strength and endurance. Successful outcomes may be achieved with a...