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Clinical Medicine Cervical and Thoracic Spine Disorders 3.1
Clinical Medicine Cervical and Thoracic Spine Disorders 3.1
24
Medical
Graduate
07/06/2018

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Term
scoliosis
Definition
• Defined as a sagittal curve > 15o
• Idiopathic- makes up more than 80% of cases
– Infantile < 3 years old
– Juvenile 4-9 years old
– Adolescent 10 plus years old
• Congenital
• Adult (degenerative)
Term
adolescent idiopathic scoliosis
Definition
• Females > males – Age 10-14
• Often associated with positive family history
• Tends to progress during puberty growth spurt

• Symptoms
– Usually asymptomatic
– Occasional back pain
– Adams test- school screening
• Physical exam
– Trunk balance
– Thoracic/lumbar prominences
– Neurologic exam typically normal

• Imaging
– PA x-ray – measure curve
– Lateral x-ray – evaluate kyphosis/lordosis
– MRI – recommended for patients with abnormal neurologic exam
Term
treatment for adolescent idiopathic scoliosis
Definition
• Bracing
– Prevent progression until skeleton matures
• Curves > 25-40o on initial presentation
• Curves > 25o with documented progression or significant growth potential
• Surgery
– Curve correction and fusion
• Curves > 40o if skeletally immature
• Curves > 50o if skeletally mature
Term
congenital scoliosis
Definition
• Results from congenital anomalies of the vertebral column
• Affects children at earlier age
• Associated with diseases of other organs (e.g. heart, kidney)

• Natural history
– Dependent upon specific deformity
– Results in asymmetric growth of the spine
– May ultimately compromise pulmonary function

• Natural history
– Dependent upon specific deformity
– Results in asymmetric growth of the spine
– May ultimately compromise pulmonary function
Term
degenerative scoliosis
Definition
• Occurs in older adults
• Results from asymmetric degeneration of the intervertebral disks
• Curve progression and imbalance may lead to nerve compression and significant disability

• Symptoms
– Pain (back vs. leg)
– Progressive deformity
– Neurologic complaints (stenosis)
• Physical exam
– Trunk imbalance
– Thoracic/lumbar
prominences
– Neurologic deficits

• Non-surgical treatment – Bracing
– NSAIDs
– Physical therapy – Injections
• Surgery
– Decompression and fusion – Higher risk of complications
Term
Kyphosis
Definition
• Deformity in the sagittal plane
Term
kyphosis treatment
Definition
• Nonsurgicaltreatment
– Observation
– Physical therapy
• Stretching/strengthening
– Bracing

• Surgery–fusion – Chronic back pain – Curves > 75o
Term
Compression Fractures
Definition
• Fracture of the anterior vertebral body
– Older patients – associated with osteoporosis
– Younger patients – occur after high-energy trauma
• Symptoms
– Back pain with no neurologic deficits
• Physical exam
– Focal tenderness
• Imaging
– Radiographs
• Measure kyphosis and collapse
– CT
• Evaluate spinal canal
– MRI
• Used to differentiate between acute and chronic fractures
• Treatment
– Natural history – majority will heal with immobilization
– Bracing
– Vertebroplasty/kyphoplasty
– Surgery
[image]
Term
Jefferson Fractures
Definition
• Description:
– Compression fracture of the bony
ring of vertebra C1, characterized by lateral masses splitting and transverse ligament tear.
• Mechanism
– Axial blow to the vertex of the head
(e.g. diving injury).
• Radiographic features:
– Key radiographic view is the AP open mouth, which shows displacement of the lateral masses of vertebrae C1 beyond the margins of the body of vertebra C2. A lateral displacement of >2 mm or unilateral displacement may be indicative of a C1 fracture. CT is required to define the extent of fracture and to detect fragments in the spinal canal.
• Stability: unstable
• Best seen odontoid view
[image]
Term
hangman's fracture
Definition
– Bilateral C2 pedicle fracture
• Through pars interaticularis
– Secondary to hyperextension of the neck (unstable)
[image]
Term
clay shoveler's fracture
Definition
– Avulsion of C6 or C7
spinous process
– Mechanism is heavy lifting

[image]
Term
cervical strain
Definition
Term
Cervical Radiculopathy
Definition
• Compression of cervical nerve root
• Most frequently arises from disk herniations or spondylosis
-spurling's test
• Imaging
– X-rays, CT may demonstrate degeneration
– MRI –
Term
cervical nerves and pain locations
Definition
[image]
Term
spurling's test
Definition
physical exam- spurling test/foraminal compression test/neck compression test/ quadrant test
-extending the neck
-rotating head
-downward pressure on head
-positive finding eliciting reprocuction of radicular pain into ipsilateral arm of head rotation
-92% sensitive, 95% specific
-low sensitivity but high specificity- not useful as a screening tool, but it does help confirm the diagnosis
Term
Cervical Myelopathy
Definition
• Compression of spinal cord
• Etiology
– Herniated disks
– Spondylosis
– Instability/trauma
– Tumors/infection
– Ossification of the posterior longitudinal ligament

• Neck pain and stiffness
– Axial neck pain (often times absent) – Occipital headache common
• Extremity paresthesias
– Diffuse non-dermatomal numbness and tingling
• Weakness and clumsiness
– Weakness and decreased manual dexterity (dropping object,
difficulty manipulating fine objects)
• Gait instability
– Patient feels "unstable" on feet
– Weakness walking up and down stairs
– Gait changes are most important clinical predictor
• Urinary retention
– Rare and only appear late in disease progression

• Physical exam – Motor
• Weakness
– usuallydifficulttodetectonphysicalexam
– lowerextremityweaknessisamoreconcerningfinding
• Finger escape sign
– whenpatientholdsfingersextendedandadducted,thesmallfinger
spontaneously abducts due to weakness of intrinsic muscle
• Grip and release test
– normallyapatientcanmakeafistandrelease20timesin10seconds. myelopathic patients may struggle to do this
– sensory
• Proprioception dysfunction
– duetodorsalcolumninvolvement – occursinadvanceddisease
– associatedwithapoorprognosis
• Decreased pain sensation
– pinpricktestingshouldbedonetolookforglobaldecreaseinsensationor
dermatomal changes
– duetoinvolvementoflateralspinothalamictract
• Vibratory changes are usually only found in severe case of long-standing myelopathy

• Upper motor neuron signs (spasticity) – hyperreflexia
• may be absent when there is concomitant peripheral nerve disease (cervical or lumbar nerve root compression, spinal stenosis, diabetes)
– inverted radial reflex
• tapping distal brachioradialis tendon produces ipsilateral finger flexion
– Hoffmann's sign
• snapping patients distal phalanx of middle finger leads to spontaneous flexion of other fingers
– Sustained clonus
• > three beats defined as sustained clonus
• sustained clonus has poor sensitivity (~13%) but high specificity (~100%) for cervical
myelopathy
– Babinski test
• considered positive with extension of great toe
• Gait and balance
– toe-to-heel walk
• patient has difficulty performing
– Romberg test
• patient stands with arms held forward and eyes closed
• loss of balance consistent with posterior column dysfunction
• Provocative tests
– Lhermitte Sign
• test is positive when extreme cervical flexion leads to electric shock-like sensations that radiate down the spine and into the extremities
-hoffmann's sign, lhermitte's sign

• Imaging – spinal cord compression on MRI (or CT myelogram)
• Natural history – symptoms will progress without surgery
• Treatment – decompression and stabilization
– Anterior – Posterior
Term
hoffmann's sign
Definition
hyperextension of distal middle finger results in flexion of thumb, index finger
Term
lhermitte's sign
Definition
"electric shock" in extremities with cervical flexion or extension
Term
cervical myelopathy cluster
Definition
age >45
gait ataxia
babinski
hoffman's reflex
inverted supinator sign
Term
Spinal Tumors
Definition
• Age
– Benign – younger patients (10-20 years old)
– Malignant, metastatic – older patients
• Location
– Benign – posterior elements
– Malignant, metastatic – vertebral body

• Symptoms
– Fever, chills
– Back pain
– Neurologic complaints
• Physical exam
– Tenderness
– Decreased ROM – Neurologic deficits

• Imaging
– X-rays
– CT
– MRI
– Nuclear medicine/PET scan
• Biopsy
– Image-guided – Open


• Treatment
– Observation/immobilization
– Radiation
– Chemotherapy
– Surgery (decompression and/or fusion)
Term
benign spinal tumors
Definition
• Osteoid osteoma
• Osteoblastoma
• Aneurysmal bone cyst
• Osteochondroma
• Hemangioma
• Giant cell tumor
• Eosinophilic granuloma
• Neurofibroma
Term
malignant spinal tumors
Definition
• Multiple myeloma • Plasmacytoma
• Osteosarcoma
• Ewing’s sarcoma • Chondrosarcoma • Chordoma
Term
most common spinal tumor
Definition
• Metastatic disease – most common spinal tumor
– Breast – Lung
– Thyroid – Kidney – Prostate
Term
spinal infections
Definition
• Vertebral osteomyelitis/diskitis
• Epidural abscess
• Postsurgical

• Organism – pyogenic vs. non-pyogenic
• Spread – hematogenous vs. direct invasion
• Location – lumbar > thoracic > cervical

• Risk factors – Obesity
– Diabetes
– Advanced age – Malnutrition
– Smoking
– Steroids
– IV drug use

• Symptoms – often nonspecific
– Back pain
– Fevers/chills
– Neurologic complaints
• Physical exam
– Focal tenderness – Decreased ROM – Neurologic deficits

• Laboratory studies
– WBC with differential
– Erythrocyte sedimentation rate
– C-reactive protein
• Imaging – X-rays
– CT
– MRI
– Nuclear medicine scans

• Infection – involves disk space
• Tumor – disk space spared

Non-surgical Treatment
• Immobilization
• Antibiotics – critical to identify organism and susceptibilities
• Minimum of 6 weeks of treatment
• Follow labs to assess response

Surgical Treatment
• Irrigation and debridement of infected tissues
• Maintain/restore alignment
• Stabilization
• High risk of complications
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