Cardiorespiratory - Logan Class of December 2011



Orthopedics

2-25-04

THORACIC SPINE

Spina bifida – common in the T11/12 area – fuse in the normal maturation process – not a big deal.

The butterfly vertebra – one side can be smaller than the other – if so there WILL be a scoliosis – there will also be a lot of kyphosis – the anterior portion will not have developed. Usually it is an insult (like in the womb – something you can’t predict – not genetic)

Kyphosis – normal is 20-50 degrees – 35 is about average – 55-60 develops problems in the chest cavity – involves the cardiac tissue then.

Senile kyphosis – the disc space are a little small, none of the vertebra are disformed – usually due to a posterior shift in the lumbar spine and a defect in the cervical spine – they do this so their eyes can be level.

Compression fracture – anterior is most common – if they have an increased kyphosis check for an osteopenic/osteoporotic compression fracture, trauma fracture if they are young.

#1 test for spinal metastasis – MRI – lab tests are not definitive – Bone scan is sensitive but not specific. MRI tells you both where and why.

ESR – good test for cancer – shouldn’t be higher than 20-25 – anyone with an ESR over 50-55 they probably have cancer. In between they probably have arthritis, etc.

Compare old films and see if there are any changes.

Hiatal hernia – obesity shoves things up into the lungs, so will an increased kyphosis.

Reverse kyphosis – no idea how that would come about – straight back syndrome – space between the ribs and the spine is decreased – not a lot of room for their heart.

Scheurermann’s disease – common – several Schmorl’s nodes on the anterior part of the vertebral body causing an increased kyphosis – usually 10-15 y/o – sometimes happens in the growth spurts – usually doesn’t hurt them – they are usually found in adults many years later – they have pain. Found in kids – the bone would be indistinct/black – it would be new and on-going – you can brace them to bring back their normal kyphosis – they haven’t solidified, so you can help correct it. Schmorl’s nodes always lead to disc degeneration.

Schmorl’s nodes – fractures of the endplate

Check sign – osteoporotic compression fracture – check sign doesn’t always mean metastasis – you need to be aggressive with your discovery – did they have cancer, when – get an MRI

Acute compression fracture – the colors are reversed from the normal T1/T2 weighted images

Thoracic spine trauma is bad news – T11/T12/L1 is the most common compression fracture of the thoracic spine

L5 pars – spondylo – these are the #1 fractures we will see

In falls where they land on their feet – check for heel fractures and Thoracolumbar fractures

T4 –T9 is the critical portion of the spine – not a good blood supply – cord space is narrower here.

Seatbelt fracture – not very common – usually severe neurological problems – sometimes see it in AS

Degenerative change between rib and vertebra –

Five causes of calcified discs –

Hyperparathyroidism

DJD - #1 cause

AS

DISH

Gout

Any deposition disease

In the thoracic spine it is a problem more so than any other place.

Middle aged women with diffuse dull achy pain between the shoulder blades – occupational stress/sprain/strain – these are the same symptoms as a classic thoracic disc bulge – no neurological signs – will go away with conservative care.

Orthopedics

3-1-04

Scoiliosis – missed the first part of the lecture

Check the following if you feel they have scoliosis (??)

Proprioception

C1- C2 for the upper extremities

Righting Reflex

Sacral area for lower extremities

Vestibular

Inner ear problems

Dizziness

Visual

Maybe the strongest input

Do a good eye exam

Righting reflex

CNS

Bottom 1/3 of their academic class, poor attention, hyperactive, when they get into college they end up in the top 1/3 of their class so it’s not an intellectual problem. What we are seeing is a prioritization process of the brain. We have higher stress levels, hormonal problems, etc., to deal with so they brain decides what needs to be dealt with at the time.

From a biomechanical and a neurological point of view maybe we can come up with a treatment plan.

Why do they start growing earlier? Genetics – when we look at the Thoracic spine, the disc is flat and the vertebral bodies are smaller in the front (gives us the kyphosis – the curves give us the stability of the spine that we need). When we lose these curves, we get a straighter spine and less stability.

The discs are bigger when they are younger. In some young girls, the disc is bigger in the front and it straightens the kyphosis – this can sometimes develop into scoliosis.

If there is a biomechanical “insult” – for example the unequal growth rate of the body; spraining their ankle, etc. – neurology kicks in – tries to get them straighter, if they body can’t accommodate with the muscles then the body balances it out by creating a scoliosis.

How can we treat this chiropractically? Lifts in kids may not be a good idea because of their sporadic and unequal growth rate. We don’t want them to get to the point of Wolfe’s Law taking over.

First we have to x-ray them – check for structural imbalances such as a hemivertebra. The films that you want to take – upright AP or PA and a lateral full spine.

The first thing that happens in scoliosis is a decrease in the AP curves, rotation of the vertebra is #2 and then comes the lateral deviation.

Then lay them on the table and laterally flex them to either side and take another film (in each laterally bent position). If the curves decrease, then that determines how much correction you can get in adjusting. If you can get it to straighten, you can probably fix the problem.

Left hand view (??) to check for chronological growth related to bone growth – melatonin is involved here somehow.

Proprioception – adjust them, rocker board. If there is an input/output problem from the cord to the muscles this can help – upper cervical and lower lumbar area.

Wolf’s Law – have them do exercises that will accentuate the movement in the spine.

Electric stim – Russian stim – square wave – can straighten them almost immediately. Put the pads on the outer edge of the ribs – uses the ribs as a lever to pull the scoliosis back into line.

Patient need to be treated Mon/Wed/Fri – electrical stim works better if done every other day (3:1 ratio – I didn’t get this). Exercises on the ball at home.

This is for a 12 year old – skeletal maturity would be a sign to quit treating them for scoliosis – Rizer’s sign is at a 4 – they are done growing. It happens as you approach maturity.

It could take as much as 3 years (depending on the state of Rizers) to correct her. See her 3 times a week for 50 weeks for 3 years - $22,800 ($50/visit). The medical route will cost $100,000 – which would you do if you were the CEO of Blue Cross/Blue Shield? I would do the less expensive route.

Scoliosis – possibly a cord problem??? Tethered cord – the bones and discs get bigger but the spinal cord doesn’t grow as fast. Melatonin has an effect on the rate of growth of the neural tissue – pulls the brain down through the foramen magnum.

Syringomyelia – may be the result of the tethered cord syndrome.

Girls go through their most rapid growth spurt 12-13 years; boys are a little older.

Orthopedics

3-3-04

Schuermann’s Disease – most common T/S problem in kids.

Painful scoliosis – usually they are painless. If there is a painful scoliosis they probably have a tumor. Osteoid osteoma is the most common – hurts at night, relieved by aspirin. Around the pedicle, around the peak of the scoliosis (T8). If you can live through the pain you can probably outgrow it. The treatments are to cut it out or give them something for pain. The surgical part is a last resort because it tends to burn out over time 6-18 months.

ARTHRITIS in the T/S

Two kinds – AS or DISH –

DISH – non-marginal syndesmophytes – hyperostosis of the ALL

AS – does the same thing –

Can’t tell – the facets will be fused in AS but not in DISH – that’s how you make the diagnosis.

DISH – bone forming people – their internal environment is predisposed to forming bone – familial – trouble swallowing

PLL calcification – very rare

AS – facets are fused front and the back – once they fuse they get extremely osteoporotic – immovable and paper thin – can break easily – be VERY careful – posterior elements are all fused

RA, Reiter’s, etc – hardly ever seen in the thoracic spine

T/S is the high ranking place for pathological fractures – compression, etc.

Disc disease, infections can happen in the T/S – high risk for this is previous surgery, immuno-compromised, drug users, low-income people – classically immigrants (TB is very common – 2 billion of the 6 billion people in the world have this)

Infections kill people faster than tumors.

Tumors – mets – primary malignant tumors in the thoracic spine are lymphomas (ivory vertabra)

Missing pedicles – tumor ate them – this is not a good sign – usually the body is eaten first.

Lung tumors – go to the T/S – they like it there – multiple myeloma – in the T/S it looks like osteoporosis (looks like this is C/S and L/S too) – starts in the T/S usually. To tell the difference it is all clinical – CBC will show a left shift, weight loss, fatigue, etc. = multiple myeloma – osteoporosis doesn’t appear “sick” – ESR will be elevated

Leukemia is the #1 tumor of kids – bone pain and weight loss are the things to look for.

Osteoid ostemoa can cause the scoliosis –

BOARDS – corduroy cloth appearance hemangioma – benign – soft tumor – hole in the back of the vertebral – check to see if the disc is involved

Paget’s disease – fuzzy cortex (fuzzy bone disease) – only disease that appears that way.

Pediatrically – pancake vertebra, silver dollar vertebra – Langerhan’s granuloma – eosinophilic granuloma – all the same thing. Single occurrence, punch out lesion, can happen any where, will grow back over time to about 90% of the original.

Hans-Christian-Schueller disease – goes to other parts (like viscera) – don’t live real long.

T/S is about 15% of your patient load – ribs, Schuermann’s, DJD

LOW BACK – article

LBP is a major public health problem in th eUS. Main reason for people under 45 limit their activities, 2nd leading cause for physician visits. 3rd most common cause for surgery. $90 billion cost

85% of the US population will have LBP (DCs will probably be more like 90%)

Recurrent, intermittent and episodic (chronic – it keeps coming back)

Only in 5% adults does it disable them.

LBP “jobs” (i.e. heavy lifting etc) have decreased but patients with LBP hasn’t – they were looking in the wrong place for the cause.

65-85% of the cost is by 10% of the LBP population- most common and most expensive cause of work-related disability in people under 45.

50% of surgeries are unnecessary and fail to relieve patient’s pain – surgeries are going up anyway.

Bed rest and acupuncture haven’t had positive affects.

SOURCE for this article is – Orthopedic Clinics of North America, 2004, Volume 35; 1-5 by Seema Pai – Low Back Pain and economic assessment in the US.

Average age is under 50, women over men, married, white

% of what they are caused by – 60% for “other and unspecified disorders of back”

MDs can’t fix this – we can – work with an MD that has LBP and they will send you patients they don’t want to/can’t treat.

Lower Extremity Pain of Lumbar Spine Origin – Differentiating Somatic Referred and Radicular Pain

Scleratogenous pain – he says it doesn’t exist. Call it somatic pain. No good pain pattern distribution with somatic pain – can’t use it to figure out where to adjust.

Name 5 lumbar orthopedics tests – LBP – 48 y/o women –

Know what they mean

SLR – 6 ways – Laying prone, supine, on either side, standing or sitting.

Step test – a standing SLR

SLR – works on traction on an inflamed sciatic nerve. Degree of elevation – doesn’t mean much other than how severe it is. Braggard’s is the most important one to do – determines whether it is hip, hamstrings, etc. pain. Dorsiflex toe – puts stress on sciatic nerve, not the hip or the hamstrings – no pain = no sciatic involvement. 85% true positive for disc bulge. WLR – raise good leg, pain down the bad leg – 90% chance it is a disc bulge and it’s bigger than you thought.

Millgrams test – raise legs and ask patient to hold them – causes pain when they try to hold them – works because psoas is firing – it is attached to the lumbar discs – only compression test for the L/S

Valsalva – increases intrathecal pressure – sac with blood vessels that surround the tissue – increases when coughing, sneezing, laughing, bearing down - all these things cause an increase in the thoracic and intra-abdominal pressure – blood vessels are increased in pressure and pushes against the cord. Indicates disc problems.

Kemp’s - + is a facet syndrome most likely, can indicate disc if the others are positive.

Orthopedics

3-8-04

LBP – L4/L5/S1 area – most common area. When it’s not there, it’s unusual.

Other locations and causes

Above L1 – chest, gallbladder, pancreas, aorta, thoracic spine

Flank – kidney, ureter, retroperitoneum, chest, gallbladder

Groin – hip, ureter, testicle, inguinal area, vascular, gastrointestinal

Buttock – pelvic, vascular, sacroiliac

Thigh –

Lumbosacral – chronic or acute

Acute – nonmechanical vs. mechanical – nonmechanical is usually more pathological (referred). Mechanical – gets better when you do something and gets worse when you do something else.

Simple mechanical – mechanical precipitant, worse with back motion, relief with rest, back pain predominates.

Radicular – radicular pain distritution, worsens with Valsalva maneuvers, neurologic symptoms, leg pain predominates.

TESTS

Simple mechanical – Limited back ROM, paraspinal muscle spasm, no traction/neurologic signs

Radicular – positive traction signs, neurologic findings

CAUSES

Simple – lumbar “strain”, early disc disease, degenerative arthritis, facet syndrome

Radicular – herniated disc, spondylosis, spondylolisthesis

OMINOUS – RED FLAG PATIENTS

HIGH RISK

Known cancer – back pain, assume it’s back

Steroid/anticoagulant therapy – corticosteroids – decreases bone density and decreases immune response so we worry about fractures and infections. Transplant patients are increasing – they are on steroids for life. Aspirin is an anti-coagulant therapy.

Elderly age – most books say 50-55

Unrelenting, progressive pain – starts on Friday, still here on Monday and it’s getting worse – caused by tumors and infections – both are killers

Fever/drug abuse/bacteremia – infection (most likely person to have this is prior back surgery 1-4% get infections – can happen 1-2 months after surgery); drug abuse – you can’t tell who’s doing it – injections with shared needles; bacteremia – needs lab work

Systemic symptoms – LBP, HA and arm hurts – probably an infection – it’s not the classic LBP presentation

History of trauma – film the area that hurts - #1 reason for law suits – not taking them

Failure to take films - #1 reason for suit – didn’t take it when they should

Symptoms

Excruciating pain, no better with rest

Fever

Weight loss

Bilateral, atypical or worrisome neurologic findings

Causes - OMINOUS

Osteomyelitis - TB

Metabolic bone disease – osteoporosis – lots of causes but osteoblasts can’t keep up with the osteoclasts

Inflammatory spondylitis – RA, SLE, AS (16-20 male, morning pain and stiffness – test is ESR and HLA B27 – treatment x-ray and adjust above and below fused segments, extension exercises and regular exercise – steroids don’t work for AS) AS will be a bigger player because it is in the sacrum. RA is hands and feet more. Women are getting it more often – about 2:1 male:female, but the symtpoms are much less severe and happens in women in their 30s. In men, it actually starts when they are about 8 years old, but symptoms don’t show until late teens/early 20’s. Diagnosis in women is a 3-4 year process. Do an ESR. Reiters and psoriatic – not as common in the SI joints – usually young men – usually feet.

Neoplasms – lumbar spine most common is mets. 95% chance of seeing secondary tumors if you take a plain film. Mets or multiple myeloma – both show up on x-ray – later in life. ESR test too (50-55 elevation)

Others (hemorrhage, abscess) -

Unstable spine (fractures) – spondylo will be the most common fraction – L5 – 7% of the population has this. Most are stable – 1 out of 100 are unstable – compression/distraction x-ray film. If they don’t respond to treatment, then take this set of films. Scar tissue has blood vessels and nerves in it – a broken pars will heal sometimes with scar tissue – it will hurt. Sometimes people have been stable for many years and then they have a car accident or fall off a ladder and it becomes unstable.

Spinal cord/canal disease – difficult to diagnose, plain films usually won’t help. Most common problem is scar tissue following surgery – MRI and CT it is hard to tell what is what because the surgery rearranges the anatomy.

Orthopedics

3-10-04

Normal endplate variants

Nuclear imaging

Cupids bow

Knife clasp deformity

Usually patients don’t have symptoms

Transitional segments

Disc of transition level usually safe, it is probably the disc above or below that herniates

2 types of spondylo we will usually see in practice

Pars fracture – repeated stress fracture – usually under 4 yoa

hyperextension – young kids usually not over the age of 20

L3/L4 denegeration facet change

Spondylo – grading

Measuring

Percentage

Compare to the one above

Compare progression

Grade 1 – 25% or less w/out neurological involvement

Grade 2-3 – some neuro involvement – most classic finding is L5 NR findings.

If you catch it early – i.e. 7 year old – back pain at L5 – suspect a problem – if you can get the ends to meet up, it will heal OK – maybe only a 5% slippage. Put them in an extension brace and limit their activity – they will heal back up and be normal the rest of their life.

35 year old – it’s too late

Dysblastic – used to be thought it was a congenital anomaly – not really – it is a spondylo that has healed – the pars elongates after the fracture.

20% slippage in 10 y/o girl – too far apart for fusion – probably been broke for 5 years – what is your concern? Slippage only occurs up to maturity – if a 35 y/o has a grade 1 it will always be a grade 1. In the 10 y/o the chance for slippage is greater – happens during growth spurts (girls this happens at about 12 y/o)

Grade 2 – increased stressed causes subchondral sclerosis.

L4 – women, black, older, degenerative

L5 – men, white, young, lytic

If the films have greater than 1-2 mm difference in distraction/compression films there is a problem. These people probably won’t respond to care and will need surgery.

BOARDS info

Bad quality x-rays on the paper – the write up will tell you what the problem is – lab values (HLA-B27, RA+, etc.) – they try to head you in the right direction. Spondylos show up pretty good.

Big things – AS, DISH, written

Ortho tests – what they mean

Orthopedics

3-15-04

Lumbar Spine – ortho/neuro test, anatomy

Transitional segments and spondylolisthesis are more common here. Diseases and tumors aren’t any more common here than anywhere else in the spine.

LBP is turning more toward conservative care – six months is about the limit – try to stay away from surgery – less than 1% of people with LBP actually will benefit from the surgery.

ON to the PELVIS

Included on the lumbar spine films.

Normal things – age differences – acetabulum growth plate, Rizzer sign (girls mature faster than boys) so it will be different in sex.

Phleboliths – these are normal – if they are above the acetabular line it could be coming down the ureter – check this one out.

TRAUMA – it is an unstable fracture – second most disastrous after skull fractures.

30% are avulsion fractures – in young adults/older children in sporting events – hockey, hurdling, etc.

ASIS – sartorius avulsion – young soccer players

Risser sign fracture – abdominal pulls

Symphysis pubis – abdominal strain

Can’t do much for these fractures – it will re-attach – sometimes not in the same place – can cause problems later. Try to get them out of the game until they heal – it will be closer to the place it avulsed from. A couple of weeks to a month is about all they need.

Most common is stress fracture – the pubic ramus – usually female – pelvis is wider – 25-35 y/o females – appears as a small area of lucency – looks more like a tumor. A month or so later, it starts to look like a callus. The callus forms when there is movement at a callus site – if she had stayed off her feet for a couple of weeks, this wouldn’t have happened. Pain pattern will be in the groin area.

The elderly women with osteoporosis will also get stress fractures here.

Osteitis pubis – irregular borders, involvement on both sides of a joint – but this isn’t an infection – groin pain – pregnant women and after delivery, men it appears after cancer/prostate surgery. It can appear anytime there is a spreading of the pelvis.

DISH likes the pubis also – changes the biomechanics of how we walk.

Lumbopelvis films – bad things like Paget’s and mets will be found more here – pelvis is the biggest flat bone in the body – mets like bones with blood. Prostate cancer (or any cancer) can be found here – blastic pattern.

Bone islands – when there is a lot of them (three in this film) – indicates carcinoma. They aren’t really bone islands but they look kinda like bone islands.

When the film looks sclerotic and patchy – carcinoma.

FOR PART IV BOARDS

Paget’s – classic case – around the acetabulum – above and around the acetabulum and down the femur. Acetabulum is the most common place for it. Starts by decreasing bone density and then increases bone density. Cortex is fuzzy. Paget’s is usually not painful – that’s the good news. Common in the elderly. Bad news – it’s not a normal bone so it fractures.

All this bone turn over can cause osteosarcoma. Knee pain in kids – this could be a possibility.

Osteosarcoma – young kids (high turnover rate because they are growing) and elderly – it is due to Paget’s or something like that.

There are drugs that can stop Paget’s. But it also stops ALL blastic bone activity.

Normal cortex is nice and sharp – fuzzy cortex – weak bone – protrusio acetabuli – most common in RA following a couple of years of steroid use (30y/o women), and young men with AS.

Fibrodysplasia – considered common but he sees it about one out of 10,000 films. Bilateral???

Most common thing we will see on our films will be the SI joint. An area of whiteness on both sides of the SI joint – this is OA. Many patients will have LBP directly related to the SI joint. Joint can be fused across the top – will affect the way we walk, etc.

Osteophytes point out toward the xray machine – so they are easy to miss. Kinda have to go on the density. Can be seen on oblique pelvic films.

Other SI changes – OCI – osteitis condensans ilii – it is bilateral so it probably isn’t mets. Increased bone stress or areas of arthritis. Lots of women with lots of children. Appears white on CT scan due to stress. They can reduce when the stress is reduced. He sees it more commonly than he does Paget’s.

AS – SI joint thing we should look for – not normal – starts out with an erosion and widening of the SI joint due to inflammation – then fuses.

30-35 y/o are going to show signs of arthritis – this just happens

RA – rare at SI joints

Reiters – rare at SI joints

Psoriatic – more of the skin stuff, pretty uncommon

Avulsion (not real common), pubic (most common fracture – stress or falls), mets (big player in the pelvis), OCI. AS, OA at SI joint. Acetabulum – missed this. Otto’s pelvis is bilateral protrusio acetabuli.

Orthopedics

3-17-04

Hip – based on patient age

Infant, Child, Adolescent, Mature, Geriatric – Male or Female

Infant – congenital hip dysplasia, female, Ortolani’s click – can be bilateral buy usually unilateral. Doesn’t show up sometimes until they try to walk.

Child – age 1-10 – painful limp, most common chief complaint is transient synovitis – inflammation of the synovium of the hip – sometimes follows traumatic event or an illness – either sex – corrects itself. Legg-Calve-Pethes – usually under the age of 4. Cause is unknown and treatment is nothing - when you see it on film there is already bone destruction. Often it is bilateral. AVN of the femur head – pathophysically the lymph and venous drainage from the head blocks up and arterial blood can’t get to it – can come from a swollen joint (could be transient synovitis), or many other things – no one knows. The bracing they used to do was to keep the weight off the femur head. If it is caught early (4-5 y/o) it is better. “Rim sign” – cartilage and edge of bone is OK but the inside of the bone is “hollow” like a ping pong ball – this is the dangerous stage – if nothing happens during this time period they will recover very well. Bed rest with traction for months seems to work in serious cases – keeps the kid in bed!!! Traction doesn’t do anything, the bed rest is what is important – keeps the weight off the femur head. Restrict their activities that would involve jumping, etc., to keep the stress at a minimum.

Adolescent – usually male, slipped capital epiphysis – 10 – 16 year olds – athletes, especially basketball and volleyball – early growth spurt people – two hormones are involved in bone growth at this time. GH itself (13 y/o for boys, 12 y/o for girls) makes the epiphyseal plate grow – the other hormone is the sex hormones (especially estrogen), which stops bone growth. They balance each other. Too much GH or not enough estrogen puts them at risk. Doesn’t happen after 16 because the plate is closed. X-ray view is the frog-leg – refer out – don’t adjust it, otherwise you get chondrolysis – rips the cartilage on both sides and destroys the hip. Surgeons put screws in to hold it – may be done on both sides if they are still going to grow a bunch.

Mature – AVN – osteonecrosis – rare in our age group. Most likely thing is trauma or trochanteric bursitis – these aren’t true hip pathologies. The difference between AVN in adults and kids (LCP) is that we can usually find the result, and we don’t heal as quickly as the kids do. If the femur head looks hollow, that’s a problem. Trauma, usually a fall on the trochanter and shoves it in. Disease – sickle cell disease, causes clumping, accumulation, thickening of the blood. Gout (possibly in our age group). Anything that thickens the blood – corticosteroids, drugs, alcoholism etc. All these will thicken the blood and cause the AVN because the blood can’t get in to it.

Geriatrics – OA is the most common – knee is #1 extremity and hip is #2. Hip surgery. Fractured hips don’t walk in to the office very often (maybe a couple times in your career you will see a stress fracture – it’s not completely broken). When they fall and break their hip, they don’t get back up. Hip fractures in the office will be because the fell going up or down your stairs or falling off your table. RA will also affect the hips, but has to be there a while.

JRA – likes the hips and knees in kids.

Lots of hip questions on the final – age, sex, fractures, diseases, etc.

Orthopedics

3-29-04

Review for Part IV xray –

If you see a skull – AP and lateral – look at the lateral. The most likely finding on a lateral skull film for board purposes is too much white or too much black (a big area = Paget’s – first stage; big area of white = Pagets; little dots = multiple myeloma; few small black dots = lytic mets) and ADI ( other measurement stuff don’t get too excited about).

Cervical spine – 3, 5, or 7 view – always look at the lateral first –

Five things that can jump out at you –

ADI

Hangman’s fracture at C2

Clay Shoveler’s fracture

Tear drop isn’t usually on the test

DJD – MOST COMMON ASKED QUESTION

Osteophytes

If it is underexposed think soft tissue swelling – classically they show it at C2 – should be no more than 7 mm. Look at the posterior arch of C2 – blood could be causing the swelling; age of patient could be infection.

Paget’s, hemangioma, etc. can only be seen on the lateral view.

Lower Cervical – First place you look is the apex of the lung – looking for a pancoast tumor. Also look for cervical ribs, tracheal deviation, calcific densities around C3 is probably carotid artery calcification, facet changes and uncinate hypertrophy.

APOM – look at this film last if you can’t find anything else, looks like fractures but they aren’t – if the dens is broken it will usually tip ant/post/left/right.

Flexion/Extension studies – ADI and/or Hangman’s fracture, Clay Shoveler’s fracture

Flexion – they are looking for ADI space changes – normal is 3 mm increase – on the test it will be GROSSLY larger

Extension –

Oblique views –

IVF problems – two findings – too big or too little

Too big – neurofibromas or aneurysms

Too small – uncinate hypertrophy, facet hypertrophy, congenital fusion

THORACIC SPINE

AP and Lateral – check apex of the lungs – should both be black. There will probably only be one T/S on the exam.

Lateral view will show the fractures – look for endplate fractures first, is it mets or osteoporosis? Schuerman’s (anterior wedging) and DISH (candlewax drippings) are usually on the thoracic view. Ivory vertebra (blastic mets, Paget’s, lymphoma, subchondral sclerosis)

Looks like DISH but isn’t is AS – AS is usually with the pelvis

Rib pathology may also show up.

Scoliosis may also show up.

LUMBAR

Lateral - Spondylolisthesis (most likely will be one of our patients) – type and grade – different in the lumbar spine than any where else.

Transitional segments on AP – won’t ask types

Tumors, mets, hemangiomas, Pagets – bone or joint disease shows up better on lateral view. Aneurysms better on lateral

AP view – six most likely things

Missing pedicles – compare to the other side – white = congenital; looks like the others = pathological

Spina bifida

Transitional segments

Soft tissue calcifications – kidney (closer to the vertebral body) or gall stones (more anterior)

Leiomyoma – women (Chondrosarcoma of the sacrum – men)

Fractured TPs don’t usually happen – but can look that way if you see the psoas shadow. (Rib fractures and TP fractures will always DISPLACE)

PELVIS – Check SI joints – are they normal??

SI joint problems – OCI and AS

Look at age – young = look at the hips (slipped capital epiphysis, LCP); old = look at the hips

Paget’s – half of the pelvis and one of the femurs

Mets – not easy to see on the pelvis

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