Conservative Management of Spinal Conditions
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Questions and Answers

What is the most common demographic for lumbar disc herniation?

  • Middle-aged individuals
  • Young adults (correct)
  • Older adults over 65
  • Children under 12

Which type of disc herniation may present with leg symptoms without back pain?

  • Foraminal disc herniation (correct)
  • Vertical herniation
  • Parasagittal disc herniation
  • Degenerative disc disease

What is a common treatment approach for Schmorl's nodes?

  • Conservative care including activity restriction (correct)
  • Long-term opioid therapy
  • Surgical intervention
  • Immediate physical therapy

At what age does the natural course of cervical degeneration begin to show in 10% of individuals?

<p>Age 25 (C)</p> Signup and view all the answers

What distinguishes cervical myelopathy, particularly in older adults?

<p>Long-track signs being the hallmark (D)</p> Signup and view all the answers

Which factors are considered when diagnosing disc pathologies typically assessed through MRI?

<p>Disc height and end plate erosions (C)</p> Signup and view all the answers

In adults, myelogram procedures are most commonly associated with which of the following?

<p>Invasive procedures throughout the body (B)</p> Signup and view all the answers

What is the primary purpose of medial branch blocks?

<p>Diagnose by blocking afferent nerve supply to the facet joint (A)</p> Signup and view all the answers

Which population is least likely to develop a non-traumatic sacral fracture?

<p>Young athletes in peak physical condition (C)</p> Signup and view all the answers

What diagnostic methods are utilized to confirm sacral fracture diagnosis?

<p>CT scan or bone scan (A)</p> Signup and view all the answers

What complication can occur acutely due to a compression fracture?

<p>Urinary retention (C)</p> Signup and view all the answers

Which type of osteoporotic fracture is characterized by an exaggerated reduction of the mid-height to posterior height ratio?

<p>Wedge fracture (C)</p> Signup and view all the answers

What symptom is most commonly associated with cervical myelopathy?

<p>Loss of balance and difficulty with gait (B)</p> Signup and view all the answers

Which condition indicates the need for a surgical referral?

<p>Progressive neurological decline (C)</p> Signup and view all the answers

Which finding would require quick referral for myelopathy?

<p>Spinal cord signal change on MRI (C)</p> Signup and view all the answers

What is a common conservative management strategy for patients with spinal issues?

<p>Bracing (C)</p> Signup and view all the answers

What percentage of patients with myelopathy experience both cervical and lumbar symptoms?

<p>13% (C)</p> Signup and view all the answers

Which of the following is a common long track sign associated with myelopathy?

<p>Clonus (C)</p> Signup and view all the answers

Why might a patient be directed towards conservative management?

<p>Patient refusal or medical inability for surgery (A)</p> Signup and view all the answers

Which of the following is NOT an indication for surgical referral?

<p>Patient directed choice (B)</p> Signup and view all the answers

What is a typical presenting symptom for cervical myelopathy?

<p>Weakness or clumsiness in the upper extremities (A)</p> Signup and view all the answers

Which of the following correctly describes the common usage of NSAIDs?

<p>They are commonly used in both acute and chronic conditions. (A)</p> Signup and view all the answers

What is the mechanism of action of NSAIDs?

<p>They inhibit the cyclooxygenase (COX) enzyme. (C)</p> Signup and view all the answers

Why are short-acting opioid agents often combined with acetaminophen?

<p>To improve the efficacy of pain relief. (C)</p> Signup and view all the answers

What is a key characteristic of anticonvulsants like Lyrica and Neurontin in the context of pain management?

<p>They are primarily used for chronic neuropathic pain. (A)</p> Signup and view all the answers

Which statement about muscle relaxants is accurate?

<p>They are primarily effective in managing acute pain. (C)</p> Signup and view all the answers

What are the potential side effects associated with NSAIDs?

<p>Hepatic, renal, gastrointestinal, and cardiovascular issues. (D)</p> Signup and view all the answers

Which of the following best describes the use of opioids for chronic non-malignant pain?

<p>They are controversial due to risks of dependence and tolerance. (D)</p> Signup and view all the answers

What determines the dosing regimen for NSAIDs in different pain conditions?

<p>The severity and nature of pain. (C)</p> Signup and view all the answers

What is a primary reason for trying several different NSAIDs for a patient?

<p>To account for variable response to given agents. (B)</p> Signup and view all the answers

What is an essential characteristic of long-acting opioid agents like OxyContin?

<p>They can alleviate (A)</p> Signup and view all the answers

What is a key consideration when using glucocorticoids for treatment?

<p>They carry minimal risk with short term usage of 1-2 weeks. (D)</p> Signup and view all the answers

What is the main effect of trigger point injections?

<p>The main effect is thought to be due to the needle itself. (A)</p> Signup and view all the answers

What type of pain fibers are responsible for transmitting sharp dermatomal pain?

<p>Small, myelinated A-delta fibers. (B)</p> Signup and view all the answers

Which statement accurately describes the role of corticosteroids in pain management?

<p>They suppress ectopic neuronal discharges among other functions. (A)</p> Signup and view all the answers

What should be performed after each therapeutic injection for pain management?

<p>Re-evaluate the patient's condition. (B)</p> Signup and view all the answers

Which type of injection is specifically indicated for radiculopathy?

<p>Epidural injections. (B)</p> Signup and view all the answers

What is the primary function of anesthetics in injections?

<p>They induce a reversible conduction block. (C)</p> Signup and view all the answers

Which area is most commonly treated with facet injections?

<p>L4-L5-S1 levels. (A)</p> Signup and view all the answers

Which aspect of nerve root pain is primarily transmitted by unmyelinated C fibers?

<p>Deep aching and sclerotomal pain. (C)</p> Signup and view all the answers

What type of injections provide both diagnostic and therapeutic benefits?

<p>Trigger point injections. (B)</p> Signup and view all the answers

What is a key limitation of medial branch blocks in providing pain relief?

<p>Nerve regeneration reduces the effectiveness over time. (B)</p> Signup and view all the answers

Which group is most prone to non-traumatic sacral fractures?

<p>Post-menopausal osteoporotic women. (C)</p> Signup and view all the answers

What is a common symptom associated with sacral fractures?

<p>Tenderness over the sacrum and potential radiating pain. (C)</p> Signup and view all the answers

Which diagnosis method is preferred for verifying a compression fracture?

<p>CT scan or bone scan. (D)</p> Signup and view all the answers

What type of osteoporotic fracture is characterized by biconcave morphology?

<p>Concave (biconcave) fractures. (C)</p> Signup and view all the answers

What determines the direction of symptoms in a disc herniation?

<p>The location and direction of herniation (D)</p> Signup and view all the answers

What are Schmorl's nodes primarily associated with?

<p>Protrusion of the disc through the vertebral endplate (B)</p> Signup and view all the answers

Which of the following is a typical symptom of cervical myelopathy?

<p>Long-track signs in individuals over 60 years old (D)</p> Signup and view all the answers

How is the treatment generally approached for Schmorl's nodes?

<p>Conservative management including bracing and activity restriction (D)</p> Signup and view all the answers

In degenerative disc disease, what percentage of individuals show symptoms by the age of 65?

<p>95% (B)</p> Signup and view all the answers

In the context of myelograms, how are conditions typically differentiated in children compared to adults?

<p>Adults usually have a history of spinal procedures (B)</p> Signup and view all the answers

What MRI finding might be missed in a foraminal disc herniation?

<p>Nerve root compression (B)</p> Signup and view all the answers

Which of the following is NOT an indication for surgical referral in patients with cervical myelopathy?

<p>Patient directed choice (D)</p> Signup and view all the answers

Which combination of findings would indicate a need for quick referral in a patient with suspected myelopathy?

<p>Bowel incontinence and urinary urgency (B)</p> Signup and view all the answers

What is the typical management approach for patients who are unable to undergo surgery for myelopathy?

<p>Conservative care and monitoring (A)</p> Signup and view all the answers

Which symptom is associated with long track signs in cervical myelopathy?

<p>Babinski reflex (A)</p> Signup and view all the answers

Which factor is crucial in assessing the need for surgical intervention in myelopathy patients?

<p>Progression of symptoms over time (C)</p> Signup and view all the answers

What aspect of care is generally prioritized in conservative management of spinal issues?

<p>Reducing the need for surgery (A)</p> Signup and view all the answers

Which long-term outcome is most concerning for patients with myelopathy who are not surgically treated?

<p>Neurological deterioration (B)</p> Signup and view all the answers

Which symptom would best indicate upper motor neuron changes in a patient with cervical myelopathy?

<p>Hyperreflexia (A)</p> Signup and view all the answers

What is a primary function of corticosteroids in the context of pain management?

<p>Interfering with inflammatory mediators (A)</p> Signup and view all the answers

What is the main effect attributed to trigger point injections?

<p>Providing a reversible conduction block (C)</p> Signup and view all the answers

Which statement best describes the usage of glucocorticoids for pain management?

<p>They should be used for severe acute pain with minimal risk when short-term. (C)</p> Signup and view all the answers

What type of pain is specifically indicated for facet injections?

<p>Axial pain with no radiation, worse when standing (D)</p> Signup and view all the answers

Which of the following injections is often utilized as an adjunct therapy?

<p>Therapeutic injections (D)</p> Signup and view all the answers

Which feature characterizes short-term usage of glucocorticoids?

<p>Minimal risk associated with 1-2 week usage (C)</p> Signup and view all the answers

Which mechanism is attributed to the efficacy of anesthetics in injections?

<p>Inducing a block of conduction in nerves (A)</p> Signup and view all the answers

What aspect of nerve root pain is transmitted by small, myelinated A-delta fibers?

<p>Sharp dermatomal pain (B)</p> Signup and view all the answers

What types of injections serve both diagnostic and therapeutic purposes?

<p>Epidural steroid injections and facet injections (C)</p> Signup and view all the answers

Which statement accurately reflects the function of fluoro-guided diagnostic injections?

<p>They can determine the effectiveness of therapeutic injections. (C)</p> Signup and view all the answers

What is the primary reason for variable patient responses to NSAIDs?

<p>Individual differences in the body's metabolism (B)</p> Signup and view all the answers

What is a significant risk associated with long-term opioid use?

<p>Increased dependency or tolerance (C)</p> Signup and view all the answers

What distinguishes the use of muscle relaxants from other pain management methods?

<p>They have a generalized central nervous system effect (C)</p> Signup and view all the answers

Why are anticonvulsants considered the drug of choice for chronic neuropathic pain?

<p>They have minimal side effects and drug interactions (A)</p> Signup and view all the answers

What is a unique characteristic of the analgesic effect of NSAIDs compared to other pain management options?

<p>They are effective in non-inflammatory conditions (A)</p> Signup and view all the answers

In managing chronic, constant pain, what dosing consideration is typically advised for NSAIDs?

<p>Longer half-life agents for sustained effect (A)</p> Signup and view all the answers

What role do antidepressants play in pain management?

<p>They are beneficial especially for chronic neuropathic pain (C)</p> Signup and view all the answers

Why is it often necessary to try several different NSAIDs for a patient?

<p>To achieve effective pain management with variable effectiveness (B)</p> Signup and view all the answers

What is the primary mechanism of action for NSAIDs?

<p>Blocking the cyclooxygenase (COX) enzyme (C)</p> Signup and view all the answers

What distinguishes the long-acting agents among opioids in terms of patient management?

<p>They can lessen anxiety about when the next dose is due (B)</p> Signup and view all the answers

Flashcards

Spinal Malalignment (New Onset)

A change in the normal alignment of the spine, often appearing suddenly.

Lumbar Disc Herniation

A condition where a portion of the spinal disc bulges or breaks out of place, potentially pressing on nerves.

Schmorl's Nodes

Vertical herniation of the disc through the vertebral endplate, usually in adolescents or older adults with a history of injury.

Foraminal Disc Herniation

A disc herniation that occurs in the spinal canal opening (foramen), causing leg pain without significant back pain.

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Cervical Degenerative Disc Disease

Degeneration of the cervical discs, leading to neck pain and potential nerve or spinal cord problems.

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Cervical Myelopathy

A condition in which the spinal cord undergoes degeneration in the cervical region, causing neurological symptoms, typically affecting individuals over 60 years of age.

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Myelogram

An imaging technique that involves injecting a contrast dye into the spinal canal to visualize structures for problems such as inflammation or infection.

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Cervical myelopathy presentation

A condition affecting the spinal cord in the neck, characterized by gradual onset of arm and leg symptoms, such as weakness or clumsiness.

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Surgical referral indications (medical perspective)

Progressive neurological decline, motor weakness, and progressive sensory loss are reasons to consider surgical intervention for spinal cord issues.

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Conservative treatment failure

When non-surgical, initial treatments like physical therapy and medication don't improve the patient's condition.

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Rapid surgery indications

Myelopathic (spinal cord) findings, bowel/bladder issues, and spinal cord MRI abnormalities suggest a need for faster surgical intervention.

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Conservative management indications

No need for referral when no surgical criteria are met; patient preference also plays a role.

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Conservative care goals

Aim to keep patients from needing surgery, and optimize their condition prior to the surgery if needed.

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Functional decline

A significant decrease in the ability to perform daily tasks.

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Bilateral UE symptoms

Symptoms affecting both upper extremities (arms).

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Myelopathic findings

Indications of spinal cord disorders, identified through various assessments.

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Neuromodulation treatment

A direct approach to managing pain or depression, not just masking symptoms.

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Titration (treatment)

Adjusting the dosage of a medication based on patient response and side effects.

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Epidural Steroid Injections (ESI)

Injections for nerve root pain (radiculopathy), not general back pain.

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Facet Joint Injections

Injections for localized axial pain, not radiating pain. It is worse when standing.

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Trigger Point Injections

Often using anesthetic, not steroids, the main effect is from the needle itself.

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Corticosteroids (injections)

Substances that control inflammation, stabilize membranes, and stop abnormal nerve signals.

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Glucocorticoids (prednisone)

Short-term use to manage severe pain, allowing therapy to begin, but not a cure.

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Injections (diagnostic/therapeutic)

Injections used to diagnose and treat pain, they should be used as an adjunct/support treatment, not a main treatment.

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Nerve Root Pain Fibers

Different types of nerve fibers transmit various sensations like vibration, temperature, and pain, each having a different type of pain signal.

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Medial Branches (MB)

Specific nerves innervating joints, originating from the dorsal rami, crucial for joint innervation.

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NSAID usage in both acute and chronic pain

NSAIDs are commonly used for both acute and chronic pain conditions because they are not sedative or addictive.

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NSAID analgesic effect

NSAIDs can reduce pain at lower doses before affecting the inflammatory process, and even in conditions not related to inflammation.

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NSAID mechanism of action

Most NSAIDs block the cyclooxygenase (COX) enzyme, which plays a role in pain and inflammation.

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Variable NSAID response

Individual responses to NSAIDs can vary significantly, requiring testing different agents to find the most suitable one.

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Opioid use in chronic pain

The use of opioids for chronic, non-cancer pain is controversial due to the risk of dependence and tolerance.

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Opioid use in acute pain

Opioids are useful for short-term and severe acute pain, such as cancer pain.

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Muscle relaxant use

Muscle relaxants, like Flexeril and Soma, have a generalized effect on the central nervous system, not a selective effect on specific muscles, making them less desirable for long-term use.

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Anticonvulsants for neuropathic pain

Anticonvulsants, such as Lyrica and Neurontin, are frequently the preferred choice for treating chronic neuropathic pain.

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Antidepressant use in pain

Antidepressants can be helpful for chronic, especially neuropathic pain.

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Dosing regimens for chronic pain

Dosing regimens vary based on pain type and severity. Shorter half-life agents are suitable for episodic pain, and longer-acting drugs are more suitable for chronic pain.

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Zygapophysial Joint Pain

Pain originating from the small joints connecting the vertebrae (facet joints). Diagnosis is often made by ruling out other potential causes.

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Medial Branch Blocks

Diagnostic injections targeting nerves supplying the facet joints. Used to confirm if pain originates from the facet joints.

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Medial Branch Radiofrequency Neurotomy

A procedure that destroys the nerves supplying the facet joints, leading to pain relief. Effects typically last for 9-12 months.

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Sacral Fracture

A fracture of the sacrum, often caused by stress or repetitive strain.

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Osteoporotic Fracture

Fracture in the spine caused by weak bones due to osteoporosis. Often manifests as a wedge-shaped or concave deformity in the vertebrae.

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Surgical referral for cervical myelopathy

Doctors refer patients for surgery when there's progressive neurological decline, motor weakness, and persistent sensory loss.

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Questions to ask for cervical myelopathy

Key questions to assess functional decline, balance, bowel and bladder function, weakness, sensory deficits, sleep quality, and psychosocial well-being.

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Degenerative Disc Disease (DDD)

A condition where the spinal discs wear down over time, leading to pain, stiffness, and potential nerve compression.

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Disc Bulge vs Herniation

A disc bulge is a slight protrusion of the disc material beyond the vertebral endplate, while a disc herniation is a complete tear in the disc, allowing the nucleus pulposus to protrude out.

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Natural Course of DDD

DDD typically starts with mild instability in the cervical spine, gradually progressing with potential pain and neurological symptoms.

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NSAID Mechanism

Most NSAIDs block the cyclooxygenase (COX) enzyme, which is involved in pain and inflammation.

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NSAID Use

NSAIDS are common for both acute and chronic pain because they're not addictive or sedative.

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Muscle Relaxants: How They Work

Muscle relaxants don't target specific muscles, they affect the whole nervous system.

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Anticonvulsants: Neuropathic Pain

Anticonvulsants, like Lyrica and Neurontin, are often the best choice for nerve pain.

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Antidepressants: Pain Relief

Antidepressants can help with chronic pain, especially nerve pain.

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Short vs. Long Acting Drugs

Short-acting drugs are for episodic pain, while long-acting drugs are for continuous pain.

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Dosing Regimen: Half-life

The half-life of a drug determines how often you need to take it.

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Neuromodulation

A direct treatment approach that targets the underlying cause of pain or depression, rather than simply masking symptoms.

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Titration

Adjusting the dosage of medication based on how a patient responds, including any side effects, to reach the optimal level.

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Side Effects as Advantages?

Some medications have side effects that can actually be beneficial for patients, especially considering the condition they are being treated for.

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Glucocorticoids (Short-term)

Steroids like prednisone can effectively manage acute pain for a limited time, but they are not a cure and long-term use carries significant risks.

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Facet Injections (Diagnostic & Therapeutic)

Injections used to determine if pain originates from the facet joints and can also provide relief from that pain, but should be considered an adjunct treatment.

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Epidural Steroid Injections

These injections are specifically used to treat nerve root pain (radiculopathy), not general back pain.

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Corticosteroids (Mechanism)

These medications work by reducing inflammation, stabilizing cell membranes, and preventing abnormal nerve signals.

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Nerve Root Pain Anatomy

Different nerve fibers transmit various sensations like vibration, temperature, and pain with varying speeds, contributing to the different pain experiences.

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Study Notes

Conservative Management of Spinal Conditions

  • Low back pain (LBP) affects many, and a trial of conservative management is often preferred over surgery.
  • The majority of surgical candidates benefit from initial conservative care.
  • Precise diagnoses are often lacking in conservative care cases. This leads to less specific treatments, with limited data supporting their effectiveness.
  • History and physical exams (H&P) are important to guide management decisions.
  • Imaging, while used, does not always correlate with symptoms. Normal scans can lead to inappropriate care if not considered within the patient's overall context.
  • Patient preferences, goals, and concerns are vital to successful management.

Differential Diagnosis of Low Back and Lower Extremity Pain

  • Spinal:

    • Lumbar radiculopathy (nerve root pain)
    • Facet joint arthritis (joint inflammation)
    • Neurogenic claudication (reduced blood flow to lower limbs due to spinal stenosis)
    • Fracture
    • Tumor
    • Infection

  • Non-Spinal:

    • Intrarticular hip pain
    • Piriformis syndrome (muscle pain in the buttocks)
    • Peripheral neuropathy (nerve damage)
    • Vascular claudication (compromised blood flow in the limbs)

General Red Flags

  • Night pain
  • Constant pain unrelated to movement
  • Constitutional symptoms (weight loss, appetite changes, fever) indicate possible serious medical issues.

Neurological Red Flags

  • Bowel or bladder dysfunction, especially urinary retention. These can signal a serious condition like cauda equina syndrome.
  • Progressive lower extremity weakness.
  • Sexual dysfunction.

Radiographic Red Flags

  • Vertebral compression fractures
  • Spinal malalignment
  • Changes in disc height or end-plate appearance.

Lumbar Disc Herniation

  • Common in young adults.
  • Can present with or without leg pain, usually caused by nerve impingement.

A. ### Discal Pathology

  • Schmorl's nodes often diagnosed with MRI
  •  Vertical herniations often relate to upper or lower thoracic segments.

Cervical Degenerative Disc Disease

  • Characterized by neck pain, radicular symptoms (pain, weakness, numbness), and myelopathy (spinal cord dysfunction).
  • This condition often has a non-inflammatory degenerative nature.

Cervical Myelopathy

  • Often associated with age (>55), and presenting with progressive neurological symptoms such as gradual onset arm and leg weakness, balance problems, wide gait, and urinary urgency.

Indications for Surgical Referral

  • Progressive neurological decline (weakening, sensory loss)
  • Functional decline
  • Failure of conservative treatments
  • Myelopathic findings (spinal cord problems)
  • Bowel or bladder incontinence
  • Other specific criteria noted in the text for each of the discussed areas of spine care

Treatment for Spinal Pain

  • Addressing pain through medication, physical therapy, and lifestyle changes
  • Various injection options
  • Surgery, as a last resort.

Types of Injections

  • Trigger point injections
  • Epidurals
  • Facet injections
  • Medial branch blocks

Treatment considerations

  • Some treatments are diagnostic (help evaluate the source of pain) while others are both diagnostic and therapeutic (to treat underlying pain).
  • Medical and psychological factors play a role in treatment.
  • Treatment decisions should consider whether the pain is of a primary nature or secondary to other medical conditions.

###Sacroiliac Joint Dysfunction

  • Pain often unilateral (one-sided).
  • Pain localized to the gluteal region.
  • Activities like walking or transitional actions can exacerbate symptoms.
  • Diagnostic imaging (like X-rays, CT scans, MRIs) and physical examination are key to identifying underlying causes.
  • SI Joint injections are a diagnostic and or therapeutic option.

###Other

  • Multiple drug interactions, especially when used concomitantly with other medications.
  • Specific medical conditions like infections, cancers, and circulatory issues can influence the type of treatment needed.

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Nonsurgical Mgmt of Spinal Conditions Notes PDF

Description

Explore the principles of conservative management for spinal conditions, focusing on low back pain (LBP) and the importance of patient history and physical exams. Understand the differential diagnoses for low back and lower extremity pain and the role of imaging in treatment decisions. This quiz is ideal for those studying orthopedic or rehabilitation practices.

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