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A 40 y.o. m presents with painful swelling on his lft MTP x2 days. You note the lesion is a red erythematous nodule that is very sensitive to palpation. He also reports that it begain at the end of guys weekend, during which he proudly states that he and his friends mostly ate steaks and drank beer. what do you suspect?
Purines are broken down by what enzyme into uric acid?
What enzyme do humans lack that alows the buildup of uric acid in the system?
Explain the pathophysiology of an acute gouty attack
monosodium urate crystals are coated with IgG which triggers opsonization. when neutrophils phagocytize the crystals it stimulates release of inflammatory cytokines, but also sometimes bursts the neutrophil releaseing all intracelluar cytokines and creating disproprotionate localized inflammatory reaction, which leads to swelling and pain
overproduction and underexcretion of uric acid creates this condition
Name some medications that cause hyperuricemia?
diuretics, low dose asprin, cyclosporine, niacin
Name two myeloproliferative disorders that cause hyperuricemia
multiple myeloma, hemoglobinopathies
70 y.o. F presents with hyper uricemia and a gouty attack on the MCP of the left hand, she is on coumadin for CVD, as well as hydrochlorothiazaide for BP, and low dose aspirin. She is very active and her favorite activity is go to to the pub to have a Guinness and listen to the band. She is fairly active and healthy other than the heart disease, her exam and labs are unremarkable except for hyperuricemia. What from her history could be causing her gouty attacks?
- The Beer
T or F Chronic kidney disease, hyperparathyroidism, psoriasis, sarcoidosis, and lead poisoning can all lead to hyperuricemia
T or F hyperuricemia invariably leads to gout
False, in most cases of hyperuricemia the patient does not develope gout
A swollen exquisitly tender nodule/nontender nodule (acute or chronic) with warm dusky red overlying skin and sometimes a white granulation tissue beneith is called a ___ and is caused by chronic gouty attacks
Trophi on the ears is associated with what?
a high uric acid level (usually around 10)
Gout of the foot especially the big toe
Why does gout typically precipitate on the first MTP?
- not good circulation
- cold temperatures
- all these factors lead to stasis and chilling of the blood which allows dissolved substances to precipitate out into crystal form more easily
You biopsy a nodule that you are unsure about, and the lab returns a report that states diffuse monosodium urate crystals found. your nodule is....
A gouty trophus
What is a possible urinary complication of hyperuricemia and gout?
uric acid kidney stones
What is a normal serum uric acid level? what is elevated?
- 3.0-7.0 mg/dL
- high = >7.5 mg/dL
T or F during a gouty attack uric acid levels may be normal
Gouty Crystals have a needle like appearance with a ___ colored perpendicular edge and a ___ colored parallel edge under polarized light
- Yellow = parallel
- Blue = perpendicular
What pathopneumonic finding will you see on X-ray of a joint with chronic gout?
"Rat Bite" erosion that has overhaning margins (overhaning rim of cortical bone with a punched out appearance)
Which of the following would be most appropriate to treat an acute gouty attack?
D. HIGH dose Colchicine
(this multiple choice question has been scrambled)
What are some indications for treating with chronic gout medications?
- multiple gouty attacks within one year (with trophi)
- advanced gouty arthritis
- renal stones
- significant hyperuricemia
What is the MOA of Colchicine?
- blocks activation of proinflammatory cytokines in monocytes and inhibits microtubule function and adhesion molecules in neutrophils to prevent migration
- (basically hog ties the monocytes and neutrophils and puts duct tape over their mouth so they can't eat any more crystals, colchicine you brute!)
What is the treatment for a patient who has gout secondary to diet or medications?
change diet and discontinue or change medications... duh!
You have a pt with history of gout who has recently also developed hypertension what two classes of drugs should you AVOID and what two class of drugs could you choose from instead?
- AVOID! thiazide and loop diuretics
- USE losartan or ARB
Name a uricosuric drug (2 mentioned in class)
Name a Xanthine Oxidase inhibitor
- Febuxostat (liver excretion use in pts with renal insuf.)
- Allopurinol ( renal excret. with risk of hypersensativ. rxns)
- Krystexxa, aka pegloticase (allergy is common give with benadryl, don't use in CHF and G6PD deficency)
What gout med should you not use for a pt with CHF or G6PD deficiency?
What age group usually gets calcium pyrophosphate dihydrate deposition disease?
elderly 60 y.o. + with an average age of 72
Males with Pseudogout tend to have more ___ while females with pseudogout tend to have more ____
- Males= Acute attacks
- Females = pseudo-ostoarthritis
What is the eitiology of the majority of pseudogout?
In this inherited disease the ankh gene for pyrophosphate transport is aberrant and pts are at higher risk of developing pseudogout
What are some diseases that can change blood calcium levels and thus increase a persons susceptibility to CPPD?
syndrome characterized by the accumulation of homogentistic acid in the connetive tissues due to autosomal recessive trait or use of phenols on the skin, this syndrome is a risk factor for CPPD
- (I know it is an obscure question but it was in her slides and because there isn't alot for this exam she could pull weird facts)
How fast do symptoms of pseudogout usually develop?
quickly 24-48 hours often after surgery
What joints are typically affected by CPPD?
Knee and larger joints
64 y.o. M presents with pain and stiffness in his right knee following a surgery for colonic resection due to diffuse diverticulitis. You note a large swollen mildly erythematous knee that is not warm to the touch. His vitals reveal that he is running a fever (all others are normal) and labs show he has a mild leukocytosis and elevated ESR. The wound site is healed nicely with no sign of infection and he denies any other complaints. What do you dx? what is your next step
Pseudogout, aspiration of the knee and visualize crystals under polarized light to confirm CPPD and rule out gout.
What joints are commonly affected with pseudogout?
What radiologic findings would you expect in a pt who has CPPD?
- calcification of cartilaginous structures
- degenerative joint disease signs
- knee, symphysis pubis and wrist disease
How would you test a joint which you suspect has CPPD
- Musculoskeletal ultrasound
An aspiration sample you sent to the lab came back as postive for bifringent rhomboid shaped crystals with blue parallel edges and yellow perpendicular edges. You feel safe making the diagnosis of...
Pseudogout or CPPD
What is the treatment for pseudogout?
- rest the joint
- splinting for joint protection
- 1-2 joint aspiration or injection
- Colchicine (for more than 2 attacks per year)
- Triamcinolone intraarticular injection
What is the indication for using colchicine in pseudogout?
more than 2 attacks per year
Cryoglobulinemia can refer to two conditions what are they? (hint: one is asymptomatic and one is symptomatic)
- - presense of asymptomatic cryoglobulins in the serum
- - Cryoglobulinemic vasculitis: symptomatic and often associated with HepC, adenovirus, parvovirus, autoimmunes
Which is more associated with APL livido reticularis, or livido racemosa?
HSP is caused by Ig_?
Which vasculitis is associated with Hep C, adenovirus, parvovirus, and other autoimmune conditions
What are the immunoglobulins/proteins that are involved with the pathology of Cryoglobulinmia
Rheumatoid factor and IgG
A 35 y.o. M presents with palpable purpura, and abdominal pain, with mild SOB. On PE you note that his toes have Reynauds phenomena and he has decreased vibratory sensation on the toes. He had a cold last week but is otherwise healthy with no other conditions. What do you think he has?
Weird bruising, peripheral neuropathy, abdominal pain, SOB, acral cyanosis, gangrene of the periphery and reynauds phenomenon as well as palpable pupura and arthralgias
How do you treat Cryoglobulinemia?
- If it is associated with Hep C then treat with antivirals like interferon alpha or ribaviran
- Immunosuppressive therapy for pts without Hep C
_____ is the most common systemic vasculitis in children
Henoch-schonlein pupura (HSP)
HSP is a leukocytoclastic vasculitis with ___ deposition
Is HSP more common in males or females?
7y.o. M presents with abdominal pain and rash on the legs. Pt has a history of prior strep infection 2 wks prior... what vasculitis should be on your differential?
What is the HSP Sx tetrad?
- Arthralgia and/or arthritis
- palpable purpura
- Renal disease
- Abdominal pain
What joints are most commonly affected with arthralgias in HSP?
Knees and ankles
T or F pts concurrent coagulopathy leads to the purpuric lesions in HSP
What causes the abdominal pain in HSP?
colicky pain in the abdomen is secondary to vasculitis of the intestinal tract and can also be associated with GI bleed
In HSP kids have worse ___ symptoms and adults have worse ___ symptoms
- Children: abdominal pain
- Adults: Kidney symptoms
uveitis, scrotal pain and tenderness and pulmonary invovement are rare symptoms of this vasculitis...
Scrotal pain/tenderness with palpable purpuric rash in a child
What are the diagnostic criteria for HSP?
- Must have at least 2 of the following
- palpable purpura
- age under 20 y.o.
- intestinal angina (abnormal pain after meals, bowel ischemia with bloody diarrhea)
- granulocytes in the walls of arterioles or venules on biopsy
You feel unsure about a pt with palpable purpuric lesions on the legs. You biopsy and the pathology report is positive for granulocytes in the walls of arterioles and venules, what do they have?
What is the treatment for HSP?
- steroid sparing agents for long term: azanthioprine, mycophenolate
- supportive care most resolve in a month
- Urinalysis/BP checks
- bed rest
- relief of joint and abdominal pain with NSAIDs
Violaceous mottling or reticular pattern of the skin on the arms and legs that is benign and reversible
Skin mottling on the arms and legs that is in a closed circle of lacy pattern
livedo reticularis is usually not invoved with other immune processes however it can be associated with which syndrome?
Lacy skin mottling on the arms and legs that is not a closed circle
Violaceous lacy mottling of the skin that is often associated with underlying autoimmune disease
What autoimmune disease is livido racemose most closely associated with
Antiphospholipid syndrome APL
This pt has a palpable purpuric rash and what they describe as a bad sinus infection. On PE you note purulent nasal discharge that is also bloody. Before you reach for the antibiotics what vasculitis should you consider?
Microscopic polyangitis (MPA)
MPA most often affects what kind of blood vessels?
small blood vessels, capillaries and arterioles
What two major body systems are affected by MPA?
- Pulmonary: causes pulmonary capillaritis, which can lead to pulmonary hemmorrhage and causes hempoptosis
- Renal: causes segmental necrotizing glomerulonephritis which manifests as hematuria, protinuria, and red blood cell casts
Your 42 y.o. patient has a palpable pupuric rash mainly on the extremities with brownish aged lesions as well as new red purpura. They also have splinter hemorrhages and vesicobullous lesions. What vasculitis is this?
What are 3 diagnostic tests you should do for MPA?
- Urinalysis: abnormal urinary sediment, microscopic hematuria with or without red cell casts, granulomatous inflammation on biopsy of an artery or perivascular area
- CXR: abnormal chest X-ray with nodules, fixed infiltrates or cavities
- ANCA testing
Is MPA ANCA positive or ANCA negative?
How do you treat microscopic polyangitis?
- Azathioprine- but give pneumocystic Jerovici prophylaxis first. it is used as a sparing agent for cyclophosphamide
What should you give to a patient with Azotihoprine to prevent complications from the drug?
pneumocystic J. prophylaxis as azothioprine decreases the bodies ability to fight off this pathogen
Is Wegener's granulomatosis ANCA positive or negative?
An ANCA+ vasculitis of the small arteries, arterioles and capillaries causing necrotizing granulomatous lesions of both the upper and lower respiratory tract, glomerulonephritis, and other organ dysfunction.
How quick is the onset of Wegener's granulomatosis?
it develops over 4-12 months (subacute)
47 y.o. M presents with a bad respiratory infection that he says has not gone away for 7 months. Sx include sinusitis, nasal congestion and a cough. He states he thought it could have been allergies but he decided to come in to get it checked because he is having trouble breathing and is coughing up blood. His ROS is positive for joint pain that is sometimes in the knee and sometimes in the elbows shoulders and hips. His PE reveals gum inflammation with an acute Otitis media and the possible beginnings of mastoiditis. He has several nasal and oral lesions. He also has stridor. What vasculitis do you think he has and what body system do you want to do lab tests for ?
- Wegener's Granulomatosis
- Renal:UA shows sediment containgin red cells with WBCs possibly but lots of red casts, renal biopsy shows segmental necrotizing glomerulonephritis with multiple crescents.
- Pulmonary: pulmonary functioning tests, CXR/CT and bony sinus CT- shows infiltrates, nodules, masses and cavities with extensive sinusitis and bony sinus erosions
ANCA has two subtypes, Against protinase-3 (or PR-3) and Myeloperoxidase subtype (MPO). These can help destinguish between Microscopic polyangitis and Wegener's granulomatosis. Which ANCA subtype goes with which disease?
- PR-3: High specificity for Wegner granulomatosis (97% +) MPA may also be positive but not as often
- Turn the 3 on its side it becomes a W
- MPO: High specificity for microscopic polyangitis and Churg strauss
- M= MPA
Tissue biopsy from the lung of a pt with palpable purpura and sinus problems shows vasculitis, granulomatous inflammation, and geographic necrosis. A Renal biopsy from the same pt shows segmental necrotizing glomerulonepritis with multiple crescents. What does your patient have?
In Wegener's granulomatosis are granulomas more common on lung or renal biopsy?
How do you treat Wegener's granulomatosis?
- Prednisone, cyclophosphamide for initial remission
- Azathioprine and/or methotrexate long term to spare the pt from having to take cyclophosphamide.
This Autoimmune disorder primarily affects women in their childbearing years and men over 60, and presents initially with painless fluctuiating muscle weakness.
What is Ocular myasthenia?
- focal extraocular motion and difficulties and drooping of the eyes
- MG that is limited to eyelides and extrocular muscles
What is Generalized myasthenia?
- weakness that involves more than just the ocular muscles
- Proximal limb weakness with deep tendon reflexes preserved
"proximal limb weakness with preserved deep tendon reflexes"
What are the two types of Juvenile myasthenia?
- transient neonatal MG
- Congenital MG
This drug can induce Myasthenia gravis
Explain the pathophysiology of Myasthenia gravis
- antibodies are formed to the acetylcholine receptors on the endplate of the posynaptic membrane/muscle surface
- they destroy the acetylcholine receptors and result in weakness
- In more detail... antibodies bind to the alpha subunit of Ach receptors and cuase damage to the postsynaptic membrane leading to decreased number and density of ach recptors on the motor end plate
With drug induced myathenia gravis remission of symptoms typically occurs how long after discontinuation of the drug?
4-6 mo but before 1 year
Symptoms of Ocular myasthenia gravis can be exacerbated by...
reading, television, driving any situation that requries continuous use of the eyes
Pt with ptosis who complains of changes in voice after prolonged conversation, trouble chewing and swallowing, and new found trouble using a straw or whistling. what disease?
Thymic hyperplasia is associated with 3 prognostic changes in disease they are...
- more severe generalized weakness
- higher acetycholine receptor antibody titers
- more severe findings on EMG
What diagnostic studies do you do for MG?
- AP and lateral chest X-ray for thymoma or MRI
- EMG studies: decrease in msucle response
- Ach antibodies: positive in 80-90% of cases
- Tensilon Test: administer edrophonium watch for resolution of sx
- EMG: decrementing muscle response is found
- PFTs: to predict respiratory failure
What is the tensilon test and what do you use it for?
Myasthenia Gravis test
- Edrophonium chloride (Tensilon test)
- + test = unequivocal resolution of weakness
- + test shows transient relief from all sx
- IV edrophonium briefly relieves weakness
- Blocks the degredation of Ach to temporarily
- increase the levels at the neuromuscular junction
- Repetitive stimulation of a nerve during a nerve
- condution study may demonstrate gradual decreases of the muscle action
- potential due to impaired nerve to muscle transmission
What is Seronegative MG?
- Seronegative myasthenia gravis= disease without
- circulating antibodies to Ach receptors
A baby born to a mother with MG has joint
contractures with muscle weakness, symmetrical and involves all 4 extremities what is the name of this condition?
What is Myasthenic crisis?
life threatening severe weakness that requires intubation
What drugs can increase MG weakness?
- Drugs increase weakness in MG- antibiotics
- (aminoglycosides, erythromycin, and azithromycin) cardiac drugs (beta-blockers,
- procainamide, and quinidine) magnesium
How can you treat Myasthenia Gravis?
- Cholinesterase inhibitors
acute immune mediated polyradiculopathy that typically follows an infection and results in paralysis
Guillian Barre Syndrome
GQ1B antibody is found in 80-90% of pts with...
Miller Fisher syndrome
This disease typically starts in the legs and arms and facial muscles and ascends over a period of about 2 wks following a viral infection
What are some non-musculoskeletal Sx of GBS
- urinary retention
- respiratory- paradoxical breathing
This is a variant of GBS that also includes opthalmoplegia, ataxia and areflexia
Miller Fisher Syndrome
This disease has inexcitable nerves on early nerve studies
What is the diagnostic criteria for GBS
- progressive weakness in more than one limb
- minimal leg weakness to paralysis of all four limbs
- includes bulbar and facial mucles
- external opthalmoplegia
- progression of sx over 4 days to 4 weeks
- relative symmetry
- mild sensory sx
- cranial nerve involvement
- recovery begins at 2-4 wks
- autonomic dysfrunction
- no fever
- elevated CSF protein more than 10mm3
How do you treat GBS?
- Supportive (monitor vitals and pain treatment with gabapentin or carbamazipine)
- plasma exchange, IVIG
- Rehab- PT
When can a pt who had a GBS follwoing an immunization by 6 wks get that immunization again?
If GBS follows an immunization how long should they not recieve any other immunizations
not until 1 yr. post GBS resolution unless the GBS followed the immunization by less than 6 wks in which case never!
____ is caused by a sympathetic response that is usually activated with inury or insult. Healing never occurs and there are abnormal impulses to stimulate the inflammatory response from teh sympathetic nervous system.
What are the two types of CRPS
- Type 1- no identifiable lesion in the area with uknown eitiology
- Type 2- identifiable nerve lesion present in the affected area
Stage II CRPS is characterized by...
- progressive soft tissue edema
- thickening of the skin and articular soft tissues
- brawny dark skin coloration plus all of the changes in stage I
Stage I CRPS is characterized by
- pain in the limb following an event or with no apparent cause
- burning/throbbing pain diffuse aching, sensitivity to touch or cold, and localized edema
- distribution of pain is not just along a single peripheral nerve trunk or root lesion but instead diffuse pain
- vasomotor disturbances occur with variable intensity producing altered colro and temperature
- radiograph may show patchy demineralization
Stage III CRPS is characterized by
- limited ROM
- shoulder and hand syndome (capsular retraction producing frozen shoulder, digital contractures, waxy atrophic skin changes with brittle ridges and nails
- bony radiograph with severe demineralization
"catchers mitt hand"
Complex regional pain syndrome
Capsular retraction producing frozen shoulder paired with digital contractures, waxy atrophic skin changes and patchy bone demineralization is called.
Shoulder and hand syndrome
- associated with CRPS, atrophy of the bone and demineralization due to chronic inflammation
- post-traumatic variant of CRPS that shows characteristic and generalized osteopenia of the area
What are the 4 categories of symptoms in the diagnostic criteria for CRPS?
Sensory symptoms of CRPS include
hyperesthesia and/or allodynia
Vasomotor symptoms of CRPS include
temperature asymetry, skin color changes and/or skin color asymetry
Sudomotor/edema sx of CRPS include
reports of edema andor sweating changes and/or sweating asymetry
Motor/trophic sx of CRPS include
reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes in the hair skin or nails
What is the treatment for CRPS?
- there is no cure
- refer to chronic pain managment
- PT is key
- nerve blocks
- smoking cessations
- oral glucocorticoids
- nasal calcitonin
a positve HLA-B27 has a high association with what disease?
What age group gets ankylosing spondylitis?
Young adult (males) 20-30 y.o.
_____ is a chronic inflammatory disease that is characterized by progressive spine stiffness moving up from the hips and lumbar spine
the point at which the tendon or ligament inserts into the bone
Explain the pathophysiology of Ankylosing spondylitis
The immune system attacks the entheses on the axial skeleton. This attack is caused by T-cell invation of the enthesis releasing inflamatory agents especially TNF alpha which leads to inflammation. This chronic inflammation leasds to granulation tissue formation calcification and ossification
What are the primary sites affected by ankylosing spondylitis?
- intervertebral disc margins, apophyseal joint capsule insertion on bone and ligamentous insertions on the spine
- sacroilliac joints are the primary site of disease
a 32 y.o. M presents to you with a dull aching in in his back that he reports has been going on for a year. He reportes that it becan in his hips and lower back and seems to be slowly getting worse. He says that is is worse in the morning and gets better after he goes to the gym before work. He is presenting to you today because for the past few weeks the back pain has been disrupting his sleep. your next course of action is..
A. Give him muscle relaxer
B. Give him a muscle relaxer and a sleep aid perscription
C. Perform a Shober's Test
C. Perform a Shober's Test, your patient is showing classic signs of ankylosing spondylitis and should be tested and possibly sent for an X-ray
(this multiple choice question has been scrambled)
If a pt with ankylosing spondylitis has acute anterior uveitis you should...
A. Treat the ankylosing spondylitis with oral prednisone the uveitis is related and should go away with treatment of the AS
B. topical medication for glaucoma
C. rever to optometry for an apointment sometime that week, preferably the next day
D. Immediate referal for urgen slit lamp examination
D. immediate referral
(this multiple choice question has been scrambled)
What are some non-axial symptoms of ankylosing spondylitis?
- synovitis of large lower extremity joints
- supraspinatus and/or achilles tendonitis or enthesopathy
- temporomandibular joint involvment
- sternocostal joint
- costosternal joint and costovertebal joints
- Cardiac: aortic root dilitation, aortic regurgitation, mitral regurgitation, conduction abnormalities, 3rd degree heart block.
- Pulmonary: Restrictive lung disease, pulmonary fibrosis of the upper lungs
What diagnostic studies do you do for a pt with ankylosing spondylitis?
- Shober's Test
- Palpation of joints: spinal paraspinal regions, ishial tuberosities, illac crests, costovertebral/costochondral, achilles tendon/plantar fascia
What are some changes on X-ray that you will see with ankylosing spondylitis?
- symmetric sacroilitis
- sclerosis of the si joint
- errosive changes
- squaring of the vertebral bodies
- syndesmocyte formation
- bamboo spine
Is a grade 4 sacroiliitis good or bad?
What is the treatment for ankylosing spondylitis?
- NSAIDs: first line, usually affective
- Peripheral Sx refractory to NSAIDS: sulfasalazine, methotrexate
- Axial Sx refrac. to NSAIDs: etanercept, infiximab, adilmumab, golimumab
- Steroid intraarticular injections
- surgery is last resort
___ is the narrowing of the spinal canal compressing nerver roots. It primarily affects the lumbar region but can occur at any point in the spine.
What are the 3 types of spinal stenosis?
- Aquired: most common, degenerative disease, trauma, post spine surgery, endocrine, metabolic, pagets
- Congenital: achondroplasia or idiopathic
- Mixed: congenital and aquired a little
What is the pathology of spinal stenosis?
narrowing of the spinal canal/intervertebral foramen caused by bone and/or ligametn hypertrophy ex. thickening of the ligamentum flavum
When does congenital spinal stenosis present?
"walking like a drunken soldier"
Back pain with relief sitting or lying or bending forward
Aching pain originating in the lower back that radiates to the buttocks and upper legs and worsens with walking or standing especially prolonged standing
What will you find on PE with a pt who has spinal stenosis?
- Focal weakness and/or sensory loss in the distribution of one or more spinal nerves
- may have absent achilles and/or patellar DTR
- wide based gait
- Postive romberg sign
What imaging study should you get for a pt with possible spinal stenosis?
What are some non-surgical treatments for spinal stenosis?
- PT: increased stabilization leads to relieved impingment
- Wt loss
- Pharmacotherapy: NSAIDs, opiates
- Epidural injections
What surgical proceedure to pts with spinal stenosis get?
Laminectomy or laminotomy
What are the most common locations for compression fracture?
T8-T12 L1 and L4
What are the two types of spinal compression fracture?
Burst and wedge
Burst compression fractures occur in the __ spine only
A person with a compression fracture will have increased pain with what movements? and decreased pain with what movements?
- standing or walking
- supine possition
What is the conservative treatment for a vertebral compression fracture?
- Analgesic Tx
- bed rest but only a few days max
- early mobilization
- PT, back stretching, lumbar strengthening
What are some indications to do surgical repair on a compression fracture?
- chronic pain refractory to conservative tx
- pain for more than 10 wks
- neck pain b/c of compensation
What are some types of surigal repair that can be done for compression fracture?
Injection of cement into the broken fragments of the vertebral body with little height correction is a surgical repair called ____
Injection and filling of a balloon inside a fractured veterbral body to create a void then inject cement into it with repair of height of the vertebrae is called
___ is caused by degeneration of the outter layers of the intervertebral disc, leading to weakening of the annulus fibrosus and tearing or fissure of the formation of the annular layers
Herniated disc disease
40 y.o. pt presents with sudden onset of sharp burning stabbing pain which radiates down posterior or lateral aspect of the leg to below the knee with knumbess and tingling after spending the day moving stones to refinish the path to his pool. He states that the pain worsens with sitting or bending and is relieved by standing or laying down.
Herniated disc disease
leaning to the opposite side of an impinged nerve root is called a ___ list
difficulty heal walking indicates...
herniated disk disease
What is the gold standard imaging for herniated disk disease?
What is the treatment for herniated disc disease?
- Bed rest for 2-7 days
- Exercise- abdominal strenghtening back extensor then back flexors
- Surgery if symptoms are refractory for more than 6 wks of conservative therapy
Non-specific back pain, urine or stool incontinence, and saddle paresthesia are all symptoms of
cauda equina syndrome
What reflex will be absent in pts with cauda equina syndrome?
What is the treatment for cauda equina syndrome?
- Emergency surgical removal of the impinging lesion
- permanent nerve damage can ensue if not corrected surgically