What patient psychosocial factors may negatively influence the decision to proceed with a spinal operation

Substance abuse (alcoholism, drug dependence), severe depression or other psychologic disturbance (e.g. borderline personality), secondary gain (litigation, financial, social), chronic pain, as well as childhood developmental risk factors (physical abuse, sexual abuse, abandonment, neglect, chemically dependent parents). 6. What is the role of Waddell signs in deciding whether or not to proceed with a lumbar spine operation A brief screening for nonorganic signs as described by Waddell is...

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,...

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...

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...

Are there any techniques that can be used to decrease the risk of construct failure when cervical corpectomies are

Depending on the pattern of neurologic compression, a hybrid corpectomy-discectomy construct may be a feasible option and can increase the stability of the construct by increasing the number of screw fixation points below the corpectomy (Fig. 46-6). Figure 46-6. A corpectomy-discectomy construct. This patient with cervical myelopathy from three disc level disease was treated with C5 corpectomy and a C6-C7 anterior discectomy and fusion. This construct allowed for additional fixation into the...

Cervical Spine Instrumentationi

Devlin, MD, Justin Munns, MD, Alexander R. Vaccaro, MD, PhD O 1. What are the indications for use of cervical spinal instrumentation To immobilize an unstable segment To correct spinal deformity To promote bony union To decrease the need for external immobilization To improve soft tissue healing 2. How are the various types of cervical spinal implants classified No universal classification exists. Cervical spinal implants may be classified descriptively by Location of...

Contributors

Clinical Professor, Orthopedics, University of California-San Diego Medical Director, San Diego Center for Spinal Disorders, La Jolla, California Richard Rothman Professor and Chair, Orthopaedics, and Professor, Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania Associate Professor, Department of Orthopaedic Surgery, Thomas Jefferson University Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania Professor, Department of Orthopedics...

Describe key points to consider in the evaluation of a patient with a suspected osteoporotic compression fracture

Vertebral compression fractures may present as acute, subacute, or chronic deformities. Statistics show that approximately 25 of radiographically detectable vertebral compression fractures are recognized clinically. The diagnosis of a vertebral compression fracture can often be made by history and physical examination. Important elements of the history would include acuity of pain onset, history of antecedent trauma, and prior fractures. Query of medical conditions that affect bone mineral...

Describe the typical clinical presentation of a patient with spinal osteoporosis

The clinical presentation can be quite variable. In general, patients with osteoporosis are asymptomatic until a fracture occurs. However, not all patients with spinal fractures are symptomatic, and the initial presentation may be a significant loss of height associated with development of an exaggerated thoracic kyphosis (dowager's hump). Many patients present with acute severe pain after minimal trauma. Paravertebral muscle spasm is common, and tenderness can often be elicited at the fracture...

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 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 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 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...

IThoracic And Lumbar Spine Fractures

Greg Anderson, MD, Todd J. Albert, MD, and Vincent J. Devlin, MD 1. Why is it important to assess radiographically the entire spinal axis when a significant spine fracture is identified in one region of the spine There is a 5 to 20 chance that a patient has a second fracture in a different region of the spine. Factors that increase the risk of missed spine fractures on initial evaluation include head injuries, intoxication, drug use, and polytrauma. 2. What factors...

L

Laminectomy cervical, 167-168, 321 described, 165, 165f electrodiagnosis after, 133 lumbar, 169-170 for lumbar spinal stenosis, 343-344, 344f, 345 for metastatic spinal disease, 446 postlaminectomy kyphosis, 282 thoracic disc, 327f for thoracic disc herniation, 168 Laminoplasty cervical, 167-168, 322 described, 165, 166f morbidities, 323 Laminotomy cervical, indications for, 167 described, 165, 165f lumbar, 169-170 for lumbar spinal stenosis, 343, 345 Lateral decubitus position, 183-184, 183f,...

Lower Cervical Spine Injuries

Steinmann, DO, and Paul A. Anderson, MD 1. Describe the initial evaluation of a trauma patient with respect to potential lower cervical spine injury. The cervical spine is immobilized in the blunt trauma patient until the spine has been cleared Initial evaluation and management is carried out according to the elements of the Advanced Trauma Life Support (ATLS) protocol The posterior cervical region is palpated for tenderness, and the patient is log rolled to...

M

Magnetic resonance imaging (MRI), 80-91 abnormal disc morphology, 84, 85-86f, 85f Magnetic resonance imaging (Continued) advantages of, 67 in cervical abnormalities, 86, 87f cervical stenosis, 94 in children with back pain, 251 computed tomography (CT) compared, 93-94 contraindications for, 81 contrast agent use, 84 in degenerative spondylolisthesis, 362, 362f disadvantages of, 67 in discitis osteomyelitis, 89, 89f lumbar disc herniation, 333 lumbar spinal stenosis, 88, 88f, 94 in metastatic...

OWinston Fong MD Scott C McGovern MD and Jeffrey C Wang MD

How does the evaluation of a patient with a spine complaint begin A complete history and physical exam are performed. The purpose of the history and physical exam is to make a provisional diagnosis that is confirmed by subsequent testing as medically indicated. 2. What are some of the key elements to assess in the history of any spine problem Chief complaint Pain, numbness, weakness, gait difficulty, deformity Symptom onset Acute vs. insidious Symptom duration Acute vs. chronic Pain location Is...

P

Complementary and alternative medicine treatments, 146-150 as indication for spinal surgery, 153 pediatric, 249-255 centralization of, 107-108 cervical causes, 104 treatment plan for, 104 chronic defined, 112 muscle relaxants for, 118 opioids for, 115, 116t patient types with, 112-113 pharmacologic management of, 112-119 sedatives-hypnotics for, 118 types, 112 defined, 112 discogenic, 120, 124, 126 leg, 417 low back assessment and management, 329-331 cardiovascular conditioning, role of,...

Sacral Fracturesp

Schildhauer, MD, and Carlo Bellabarba, MD O 1. What is the role of the sacrum The sacrum connects the lumbar spine and the left- and right-sided iliac wings by means of well-developed ligaments with little inherent bony stability. The sacrum is kyphotically aligned in the sagittal plane in a variable dimension ranging from 0 to over 90 . The sacrum distributes the torso load from the lumbar spine mainly through its S1 segment into the sacroiliac joints and...

Spinal Cord Injury

Which of the following terms are currently favored to describe impairment or loss of motor and or sensory function due to damage of neural elements within the spinal canal (1) tetraplegia, (2) paraplegia, (3) quadriplegia, (4) quadriparesis, and or (5) paraparesis Tetraplegia refers to the impairments resulting from damage to neural elements within the cervical spinal canal, whereas paraplegia refers to the impairments resulting from damage to neural elements within the thoracic, lumbar, or...

Upper Cervical Spine Trauma

Bransford, MD 1. What are the major types of injuries involving the upper cervical (occiput-C2) region The major types of injuries can be classified according to location 1. Occipitocervical articulation 3. Axis (C2) Occipital condyle fractures Odontoid fractures Atlanto-occipital dislocation Hangman's fractures Transverse ligament injuries 2. How are upper cervical spine injuries diagnosed Any patient with a suspected cervical spine injury requires a...

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 are flexion exercises Williams exercises When are they appropriate

Apple Pencil Poster

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 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 of the warning signs that opioids are being abused

Certain actions have been identified as being highly suggestive of addictive behavior. They include selling prescription drugs, forging prescriptions, repeatedly borrowing drugs from friends or family, concurrent use of large amounts of alcohol, use of any illicit street drugs, the loss of prescriptions or pills, seeking prescriptions from other doctors including emergency department personnel, and frequent missed appointments. Other signs that may raise the suspicion of drug abuse include...

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 daily recommended vitamin D and calcium requirements

The daily adult requirement for vitamin D is 800 to 1000 units. The daily adult requirement for calcium (Ca) is 1200 mg for the 26-49 year age group. Recommendations regarding daily requirements are based on patient age and are frequently updated to reflect the current state of scientific knowledge See Table 65-2. Table 65-2. Daily Calcium Requirements REQUIREMENT (MG OF ELEMENTAL CA DAY)

What are the different types of peripherally acting analgesics

The peripherally acting analgesics are acetaminophen and the NSAIDs, including aspirin. They are useful for mild to moderate pain and may also act synergistically with centrally acting analgesics. The NSAIDs have two mechanisms to relieve pain, an antiinflammatory effect and a pure analgesic action. Empiric support for this includes the fact that analgesia can begin in less than an hour, long before any antiinflammatory activity could occur, and NSAIDs may relieve pain even when there is no...

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 most common types of intraduralextramedullary spinal cord tumors

Eighty percent of the tumors in the intradural-extramedullary space are schwannomas, neurofibromas, or meningiomas (Fig. 62-3). Tumors of the intradural-extramedullary space account for 60 of all intradural spinal tumors in adults but are less common in children. Nerve sheath tumors (schwannomas, neurofibromas) arise from sheath cells covering the spinal nerve roots while meningiomas arise from meningeal cells localized at the spinal cord surface. Neurofibromas occur commonly in patients with...

What are the most common types of intramedullary spinal cord tumors

The most common types of intramedullary tumors (Table 62-3, Fig. 62-4) are ependymomas, astrocytomas, and hemangioblastomas. In children, astrocytomas are the most common tumor type, while in adults, ependymomas are most common. Ependymomas arise from the cuboidal ependymal cells that surround the ventricular system and central canal of the spinal cord. As the tumor enlarges in the central canal, the flow of CSF is obstructed and cystic cavities frequently develop above and below the lesion....

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 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 is a good way to select from among the many NSAIDs

NSAIDs may be classified as nonselective or traditional NSAIDS (e.g. ibuprofen, naproxen) and selective NSAIDS or COX-2 inhibitors (e.g. celecoxib). Traditional NSAIDs act as nonselective inhibitors of the enzyme cyclooxygenase and inhibit both cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2). Selective NSAIDs were developed in an attempt to provide antiinflammatory action without the gastrointestinal adverse drug reactions attributed to inhibition of COX-1. Additional complications...

What is cervical myelopathy and how does it develop

Cervical myelopathy is the most common cause of spinal cord dysfunction in patients older than age 55. Spinal cord dysfunction arises secondary to spinal cord compression, a diminished vascular supply, or both. In some patients, spinal cord compression occurs due to a congenitally narrowed spinal canal. In the majority of patients, spinal cord dysfunction occurs secondary to compression by degenerative changes associated with the normal aging process. Progressive cervical spondylosis may lead...

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 natural history of cervical radiculopathy

Cervical radiculopathy most commonly results from nerve root compression due to a herniated disc and or cervical spondylosis. In most cases there is no preceding trauma. Patients commonly present with neck pain, headache, and sharp pain radiating to the upper extremity in a dermatomal distribution. Neck movement, cough, and Valsalva maneuvers tend to exacerbate pain symptoms. Numbness and paresthesias occur most commonly in the distal part of the involved dermatome. Patients may present with...

What is the role of therapeutic injections

Therapeutic injections are used to reduce pain and inflammation and permit initiation of an exercise program. Local trigger point injections can be done with local anesthetic, with or without steroid, NSAIDs, botulinum toxin, or 5-HT3 receptor antagonists. The analgesic action is explained by inhibition of dorsal horn efferents by nociceptive counter irritant based on gate control theory. Botulinum toxin can be used to decrease painful muscle spasm by blocking acetylcholine release in trigger...

What is the typical pattern on technetium bone scan in a patient with acute vertebral compression fractures secondary

The typical appearance of osteoporotic compression fractures on a technetium bone scan (Fig. 13-3) consists of multiple transverse bands of increased uptake on a posteroanterior image. However, the etiology of the fracture (trauma, tumor, metabolic bone disease) cannot be definitively diagnosed based solely on a bone scan. Increased activity can be noted within 72 hours of fracture, and the average time for a bone scan to revert to normal following an osteoporotic vertebral compression fracture...

What nonspinal disorders must be ruled out during the examination of a patient with degenerative spondylolisthesis

Degenerative arthritis of the hip joint and peripheral vascular disease. Hip joint arthrosis may cause buttock and thigh pain that mimics the symptoms of spinal stenosis. Assessment of hip joint range of motion can determine whether radiographs are necessary to evaluate the hip joints. If both hip arthritis and degenerative spondylolisthesis are present, injection of the hip joint under fluoroscopic guidance can aid in sorting out which problem is more symptomatic. Peripheral vascular disease...

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 are sacroiliac SI joint injections indicated

Patient history and physical examination have been shown to be unreliable in the diagnosis of SI joint pain. An analgesic response to a properly performed diagnostic SI joint block is considered the most reliable test to diagnose SI joint-mediated pain. Patients with low back, buttock, or groin pain not attributed to other causes can be considered for SI joint injection. The patient is positioned in the prone oblique position to facilitate visualization of the inferior portion of the joint. A...

When is cervical TDR an appropriate option for treatment of cervical myelopathy

Cervical total disc arthroplasty has been shown to be successful for treatment of select patients with cervical myelopathy in whom spinal cord compression is localized to the level of the disc space (retrodiscal). This procedure is not appropriate for patients with severe facet joint degenerative changes at the operative level, severe loss of disc space height, myelopathy due to congenital spinal canal narrowing, and cervical stenosis due to retrovertebral cord compression (e.g. ossification of...

Which muscle relaxants might be helpful for shortterm use

Cyclobenzaprine (Flexeril) is chemically similar to amitriptyline and may be useful for patients who have a sleep disturbance and decline antidepressants. The dose is 10 mg at night. Baclofen can be effective for the relief of painful spasms, although its effect is in the central nervous system rather than on the muscles. It is started at 10 mg at night and then gradually titrated up to 10 mg every 6 hours. Some other muscle relaxants are orphenadrine (Norflex), carisoprodol (Soma),...

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...

Winston Fong MD Scott C McGovern MD and Jeffrey C Wang MD

What are the most common reasons for referral to evaluate the thoracic spinal region Pain and spinal deformity. The differential diagnosis of thoracic pain is extensive and includes both spinal and nonspinal etiologies. Spinal deformities (e.g., scoliosis, kyphosis) are generally painless in children but may become symptomatic in adult life. 2. What are some common spinal causes of thoracic pain Degenerative disorders spondylosis, spinal stenosis, disc herniation Fracture traumatic, pathologic...

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...

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...

B

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...

What is the anatomic basis for EDX as it relates to the assessment of spinal disorders

Metatarsophalangeal Joint

The purpose of the EDX is to assess the motor and sensory function related to the spinal nerves. Each spinal nerve contains both motor and sensory fibers and contributes to the formation of the peripheral nerve. The cell bodies for the motor axons are situated within the anterior horn of the spinal cord. The cell bodies for the sensory axons are located within the dorsal root ganglion near its junction with the ventral root. There it forms the mixed spinal nerve in the region of the...

Define ankylosing spondylitis

Ankylosing Spondylitis Ray

Ankylosing spondylitis (AS) is a seronegative inflammatory arthritis of the spine of unknown etiology. It presents in the early stages with an inflammatory arthritic pain that typically involves the sacroiliac joints initially and later the other spinal regions. The classic feature of AS is enthesopathy (inflammation at the attachments of ligaments, tendons, and joint capsules to bone). Initially, range of motion is normal or mildly limited. Disease progression leads to spinal ossification,...

Explain how EMG is used to assess patients with spinal disorders for the presence of a radiculopathy

Specific muscles are selected for EMG assessment. Six upper limb muscles, including paraspinal muscles, consistently identify more than 98 of cervical radiculopathies that are confirmable by electrodiagnosis. For upper-limb EMG evaluation, a suggested screen includes deltoid, triceps, pronator teres, abductor pollicis brevis, extensor digitorum communis, and cervical paraspinal muscles. Six lower limb muscles, including paraspinal muscles, consistently identify more than 98 of...

Are anterior approaches commonly performed today for the treatment of adult scoliosis

As a result of the potential morbidity from an anterior approach and the fact that recent data suggest the same correction and similar fusion rates are achievable through a posterior-only approach, the enthusiasm for anterior fusions or combined anterior posterior fusions for adult spinal deformity has declined over recent years. A mini-open anterior retroperitoneal approach is, however, still commonly performed to achieve anterior column structural interbody grafting at caudal segments of a...

How is a PET scan performed

A positron-emitting radionuclide is injected into the body. As the positrons are emitted and travel through tissue they collide with electrons, resulting in production of gamma rays. A PET scanner records and analyzes these data and creates an image. CT or MRI may be combined with PET to maximize diagnostic potential. FDG is currently the most commonly used radiotracer. It is transported and becomes trapped intracellular as a result of phosphorylation by hexokinase. FDG accumulates at sites of...

How does RA affect the cervical spine

Rheumatoid Arthritis Anaesthesia Spine

The cervical spine is composed of 32 synovial joints. The occiput-C1 and C1-C2 articulations rely on soft tissue integrity for stability. In the subaxial cervical spine, the facet joints are true synovial joints. Rheumatoid pannus produces enzymes that destroy cartilage, ligaments, tendons, and bone. This synovitis leads to spinal instability, subluxation, and spinal deformity. Secondarily, the discs in the subaxial spine degenerate, which may result in additional facet joint subluxation and or...

What CAM treatments work best for the treatment of back pain

Popularity or personal testimonials do not prove or disprove treatment efficacy. CAM therapies are most frequently administered in combination with traditional therapeutic interventions for back pain using nonstandardized protocols. The medical evidence to support specific CAM treatments for back pain may be unavailable, insufficient, or conflicting depending on the specific intervention that is evaluated. Nevertheless, standardized reviews and randomized controlled trials have been published...

How is the clinical syndrome of lumbar DDD characterized

Lumbar DDD refers to a continuum of nonradicular pain disorders of degenerative origin. Specifically excluded are symptoms related to disc impingement on neural elements, facet-mediated back pain, and spinal deformities secondary to lumbar DDD (e.g. spondylolisthesis, degenerative scoliosis). Presenting symptom is primarily low back pain, which may radiate to the sacroiliac and or buttock region. Common physical examination findings include tenderness with palpation over the lumbar region and...

Describe the course of the vertebral artery in the cervical spine

Vertebral Artery

The vertebral artery arises from the subclavian artery. It enters the transverse foramen at C6 in 95 of people and courses upward through the foramina above. At C1, the vertebral artery exits from the foramen, courses medially on the superior groove of the posterior ring of the atlas, and enters the foramen magnum to unite with the opposite vertebral artery to form the basilar artery. Figure 25-2. Vertebral artery. (From Winter R, Lonstein J, Denis F, et al. Posterior upper cervical procedures...

What are the different types of osteoporosis

Osteoporosis has been classified into two major types primary and secondary. Primary osteoporosis is further subdivided into type 1 or postmenopausal osteoporosis and type 2 or senile osteoporosis Type 1 osteoporosis is due to estrogen deficiency and typically occurs in women 5 to 10 years after menopause. It predominantly affects trabecular bone and is associated with vertebral fractures, intertrochanteric hip fractures, and distal radius fractures Figure 65-1. Specimen radiographs of 2-mm...

What is the degenerative cascade

The term degenerative cascade was introduced by Dr. Kirkaldy-Willis to explain the typical progression of lumbar spine degeneration. This process is conceptualized in terms of a three-joint complex composed of the intervertebral disc and two zygoapophyseal joints that comprise a functional spinal unit, the smallest anatomic unit of the spinal column that demonstrates its basic functional characteristics. The progression of degenerative changes involving the three-joint complex is conceptualized...

R

Radiation therapy, for metastatic spinal disease, 445 Radicular artery of Adamkiewicz, 22 Radiculopathy cervical computed tomography, 93 described, 36 disc replacement, 320 electrodiagnosis, 132 magnetic resonance imaging (MRI), 86, 93 natural history of, 104 nonsurgical treatment plan for, 105 provocative maneuvers for evaluation, 36 electrodiagnosis, 129, 130-131, 130t, 132-133 lumbar electrodiagnosis, 132 nonsurgical treatment plan for, 106 thoracic electrodiagnosis, 132-133 treatment plan...

Provide a brief description of the types of mindbody therapy that have been used to treat patients with LBP

Cognitive-behavioral programs are a component of many established pain treatment centers. These programs focus on educating patients and teaching coping skills in a highly structured group setting under the guidance of a clinical psychologist. They frequently incorporate hypnosis, meditation, and biofeedback techniques 2. The Alexander technique is a method of modifying chronic patterns of back and neck muscle tension through an instructor's verbal direction and awareness exercises. Patients...

What are the options for reconstruction of the anterior and middle spinal columns after resection of a metastatic

Options for reconstruction of the anterior and middle spinal columns include bone graft (autograft or allograft), methylmethacrylate, titanium mesh cages, and carbon fiber or polyether ether ketone (PEEK) cages. Expandable cages have been popularized for use in this setting. All of these intracolumnar implants are used in combination with anterior spinal instrumentation (plate systems, rod systems) and or posterior segmental spinal fixation. 29. What is the role of kyphoplasty and...

What is the crankshaft phenomenon

Crankshaft phenomenon refers to continued anterior spinal growth after posterior spinal fusion in a skeletally immature patient, resulting in increased spinal deformity. Risk factors include skeletal immaturity (Risser stage 0, premenstrual, open triradiate cartilage), surgery before the peak growth period (prior to 10 years of age) and large residual curves after initial surgery. The traditional approach for prevention of crankshaft phenomenon is to perform an anterior spinal fusion in...

Cervical Spine Injuries In Athletesi

Watkins, IV, MD, and Robert G. Watkins, III, MD O 1. What sports are associated with the highest risk for head and neck injuries The organized sports with the highest risk for head and neck injuries are football, gymnastics, wrestling, and ice hockey. Football is the sport associated with the highest risk of such injuries. Head and neck injuries also occur in a variety of nonorganized sports activities including diving, skiing, surfing, and trampoline use. 2. What types of cervical...

What is Pagets disease

Mitch Paget

Paget's disease is named after Sir James Paget, who described its clinical and pathologic aspects in 1876. Paget's disease is the second most common metabolic bone disease. It has been found in up to 5 of northern European adults older than 55 years. However, most affected individuals are asymptomatic. The cause is unknown, but viral infection and genetic factors are believed to be responsible. The disease causes focal enlargement and deformity of the skeleton. The pathologic lesion is abnormal...

What is lifting capacity

Lifting capacity assesses the spinal functional unit (extensor unit lumbar paraspinals, gluteals, and hamstrings) and its interaction with the body's other functional units in performance of activities of daily living. Patients with chronic low back pain have a 30 to 50 reduction in lifting capacity. Normal lifting capacity from floor to waist (lumbar lift) is approximately 50 of IBW for men and 35 of IBW for women. Normal lifting capacity from waist to shoulder (cervical lift) is 40 of IBW for...

Lumbar Spine Injuries In Athletesi

Watkins, V MD, and Robert G. Watkins, III, MD O 1. What is the differential diagnosis for an athlete who presents with symptoms of low back pain with or without radiculopathy Muscle strain ligament sprain Lumbar disc injury (annular tear, discogenic pain syndrome, disc herniation) Ring apophyseal injury (adolescents) Stress fracture (e.g. spondylolysis, sacral stress fracture) Minor lumbar fracture (e.g. transverse process fracture) Serious underlying spinal condition (discitis...