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TRAUMA & ORTHO > 10: Cervical and Thoracic spine, Brachial Plexus, Axilla and Pectoral Region > Flashcards

10: Cervical and Thoracic spine, Brachial Plexus, Axilla and Pectoral Region Flashcards

1
Q

what is cervical spondylosis

A

chronic degenerative OA affecting intervertebral joints in cervical spine
- primary pathology is usually age-related disc degeneration, followed by marginal osteophytosis (osteophyte formation adjacent to end plates of vertebral bodies) and facet joint OA
- narrowing of intervertebral foramina can put pressure on spinal nerves –> radiculopathy
- symptoms of radiculopathy include: dermatomal sensory symptoms (e.g paraesthesia, pain) and myotomal motor weakness

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2
Q

what can happen if degeneration in cervical spondylosis leads to narrowing of spinal canal

A

can put pressure on spinal cord –> myelopathy
- less common outcome than radiculopathy and can manifest as global muscle weakness, gait dysfunction, loss of balance and/or loss of bowel and bladder control
- symptoms arise due to compression and dysfunction of ascending and descending tracts w/in the spinal cord

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3
Q

Jefferson’s fracture

A

fracture of the anterior and posterior arches of the atlas vertebra (C1)
- mechanism of injury is axial loading e.g. diving into shallow water, impacting head against roof of vehicle or falling from playground equipment
- causes C1 vertebra to burst open but this reduces likelihood of impingement on spinal cord so pain but no neurological signs
- can however sometimes be damage to arteries at base of skull –> secondary neurological sequelae e.g. ataxia, stroke, Horner’s syndrome

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4
Q

Hangman’s fracture

A

axis vertebra (C2) fractured through the pars interarticularis which is the region between the superior and inferior articular processes
- mechanism of injury: usually forcible hyperextension of head on neck e.g. road traffic collisions
- unstable fracture which requires treatment
- similar to C1 fractures, the configruration expands the spinal canal so reduces risk of associated spinal cord injury

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5
Q

fractures of the odontoid process (peg fractures)

A
  • cause be caused by either flexion or extension injuries
  • most commonly seen mechanism is an elderly patient w osteoporosis falling forwards and impacting forehead on pavement
  • hyperextension injury of cervical spine can result in fracture of odontoid peg
  • can also be caused by blow to back of the head (hyperflexion injury e.g. falling against wall when balance compromised)
  • fracture can be detected on ‘open mouth’ AP X-ray or CT of cervical spine
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6
Q

why is the cervical spine prone to whiplash injury

A
  • head accounts for 7-10% of total body weight
  • balanced on cervical spine which has high mobility and low staibility
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7
Q

explain the mechanism behind a whiplash injury

A

forceful hyperextension-hyperflexion injury of cervical spine
- at time of impact, vehicle suddenly accelerates forward
- approx 100ms later, pt’s trunk and shoulders follow
- w no force acting on it, pt head remains static in space = forced extension of the neck as shoulders travel anteriorly under head
- with this extension, inertia of head is overcome and head accelerates forward
- neck acts a lever to inc forward acceleration of head, forcing neck into flexion
- hyperextension followed by hyperflexion = tearing of cervical muscles and ligaments
- secondary oedema, haemorrhage and inflammation can occur
- muscles respond to injury by contraction (spasm), w surrounding muscles being recruited in an attempt to splint injured muscle = pain and stiffness

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8
Q

symptoms following whiplash injury

A
  • can complain of arm pain and paraesthesia as result of injury to spinal nerves during whiplash movement of cervical spine
  • shoulder injuries due to holding steering wheel at time of collision
  • lower back pain in approx 40-50%
  • chronic myofascial pain syndrome as a secondary tissue response to disc or facet-joint injury
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9
Q

can whiplash result in injury to spinal cord?

A

sometimes, despite there being no accompanying bone fracture
- cervical spine = highly mobile and ligaments and capsule of joints are weak and loose so there can be sublxation or dislocation of vertebrae at time of impact with return to normal anatomical position after
- soft tissue swelling may be the only visbile feature on imaging

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10
Q

what is a protective factor against spinal cord injury

A

large vertebral foramen relative to diameter of cord

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11
Q

describe the mechanism of cervical intervertebral disc prolpase

A
  • similar to that of lumbar spine where tear develops in annulus fibrosus of disc and nucleus pulposus protrudes from disc w impingement onto adjacent nerve root or spinal cord
  • in cervical reginon it is the spinal cord and not the cauda equina that is compressed
  • sometimes sequestration occurs in which an extruded segment of nucelus pulposus separates from main body of disc and enters spinal canal where it is resorbed over period of weeks w resolution of symptoms
  • may be spontaneous in origin or may even be related to trauma and neck injury
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12
Q

why is even a small disc hernation in the cervical spine likely to cause significant pain

A

discs are small and little space available for exiting nerves unlike lumbar spine so even small cervical disc herniation may impinge on nerve = pain

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13
Q

symptoms of cervical intervertebral disc prolapse

A

dependent on site of prolpase
- paracentral prolpase may impinge on spinal nerve –> radiculopathy
- canal-filling prolapse –> acute spinal cord compression

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14
Q

what will a patient complain of in a left-sided C5/6 prolapse

A

NOTE: cervical nerves exit above their respective vertebrae so exiting root at C5/C6 = C6. They also travel much more horizontally from spinal cord to intervertebral foramen than lumbar nerves so = no traversing nerve root, just an exiting nerve root (so nerve being compressed = C6)
- pt may complain of paraesthesia in left C6 dermatome (radial border of left forearm, thumb and index finger)
- weakness in left C6 myotome (weakness of left elbow flexion, supination and wrist extension)
- pain in neck that will radiate down left arm often felt over biceps and into skin supplied by C6 dermatome

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15
Q

what is cervical myelopathy

A

spinal cord dysfunction due to compression of cord caused by narrowing of spinal (vertebral) canal

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16
Q

what is cervical spondylotic myelopathy

A

myelopathy secondary to cervical spondylosis
- result of degen changes which develop w age, including ligamentum flavum hypertrophy or buckling, facet joint hypertophy, disc protrusion and osteophyte formation
- one or all changes contribute to overall reduction in canal diameter –> cord compression

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17
Q

what causes cervical myelopathy

A
  • common cause: degenerative stenosis of spinal canal caused by cervical spondylosis (degen OA) which most commonly affects 50-80 year olds
  • congenital stenosis of spinal canal
  • cervical disc herniation
  • spondylolisthesis (anterior slippage of v. body on vertebra below)
  • trauma
  • tumour
  • OA
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18
Q

what causes symptoms of cervical myelopathy

A

compression of long tracts in spinal cord
- average diameter of cervical canal =17-18mm; if >12-14mm, myelopathic symptoms may be experienced

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19
Q

how might a patient w cervical myelopathy present

A

range of symptoms, many of which are non-specific
- can also manifest w upper limb symptoms due to damage to long tracts of spinal cord
- classic presentation: loss of balance w poor coordination, decreased dexterity, weakness, numbness and paralysis in severe cases
- pain can be symptom but often absent which delays diagnosis
- in older pt = rapid deterioration of gait and hand function

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20
Q

what can upper cervical lesions lead to

A

loss of manual dexterity w difficulties in writing and nonspecific alteration in arm weakness and sensation
- pt may demonstrate dysdiadochokinesia (impaired ability to perform rapid alternating movements)

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21
Q

what can lower cervical lesions lead to

A

spasticity (inc muscle tone, sometimes w clonus) and loss of proprioception in legs
- pt commonly say that their legs feel heavy and reduced exercise tolerance
- gait disturbances and may suffer multiple falls

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22
Q

function of long tracts and how are they are impacted in cercical myelopathy

A

normally dampen spinal reflexes so a person does not overreact to stimuli
- when damaged, protective capabilities are less effective and pt may demonstrate exaggerated response to stimuli (positive Hoffman’s or Babinksi sign)

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23
Q

describe Hoffman’s test

A
  • doctor hold pt middle finger at middle phalanx and flicks finger nail
  • if there is no movement in index finger or thumb after this motion, pt has -ve Hoffman’s sign which is normal
  • if index finger and thumb move, pt has +ve Hoffman’s sign (abnormal)
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24
Q

Babinski sign

A
  • lateral side of sole of foot stroked w blunt instrument from heel towards the toes
  • normally in children over the age of approximately 2-3 years and adults, the response is flexor in that the toes flex downwards towards the sole (plantarflex)
  • +ve Babinksi (abnormal): hallux dorsiflexes and the toes fan out
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25
Q

what is L’Hermitte’s phenomenon

A

sensation of intermittent electric shocks in the limbs, exacerbated by neck flexion
- classically associated w cervical myelopathy
- when compression is severe, if surgical decompression is not performed, symptoms may progress to sphincter dysfunction and quadriplegia

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26
Q

what are the likely signs and symptoms if a pt develops myelopathy of the cervical spine at level of C5

A
  • pain: neck pain
  • sensory: paraesthesia from shoulder (C5 dermatome) distally, trunk and lower limbs
  • motor weakness: weakness of shoudlder abduction and lateral rotation; weakness of all myotomes distally + trunk and lower limbs
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27
Q

what are the most common causes of thoracic cord compression

A
  • vertebral fractures (w bony fragments in spinal canal
  • tumours in spinal canal
28
Q

what are the most common cancers that arise from solid organs and spread to bone

A
  • breast
  • lung
  • thyroid
  • kidney
  • prostate
29
Q

what is important to note when thinking about the level of cord compression

A

in the thoracic and lumbar spine, the neural segments do not line up w their respective vertebral segments bc spinal cord is much shorter than vertebral column
- so a metastasis in T12 vertebra impinging on spinal canal would compress L4-L5 segments of spinal cord

30
Q

via what three routes can pathogens reach the bones and tissues of the spine

A
  • haematogenous
    - spread from a septic focus elsewhere in the body is the most common route and typically occurs via arteral supply to the vertebral bodies but also through retrograde venous flow
  • direct inoculation during invasive spinal procedure e.g. lumbar puncture, epidural or spinal anaesthesia
  • spread from adjacent soft tissue infection
31
Q

what is spondylodiscitis or discitis

A

infection of the intervertebral
- most commonly occurs in immunocompromised pt e.g. those w diabetes , HIV and pt on steroids
- in adults, intervertebral disc is avascular and it is thought that organisms are therefore initially deposited in vertebral body via segmental artery –> bony ischaemia and infarction
- necrosis of bone then allows direct spread of organisms into the adjacent disc space, epidural space and adjacent vertebral bodies

32
Q

via what mechanisms does spread of infection into spinal canal lead to neurological damage

A
  • septic thrombosis –> ischaemia
  • compression of neural elements by abscess/inflamm tissue
  • direct invasion of enural elements by inflamm tissue
  • mechanical collapse of bone –> instability, particularly in chronic infections
33
Q

most common organisms causing infection

A

staphylococcus aureus and gram -ve bacilli e.g. escherichia coli
- following invasive spinal procedures, coagulase-negative Staphylococci become more frequent
- infections w more unusual organisms e.g. pseudomonas, candida may be seen in injecting drug users

34
Q

C5 myotome

A

shoulder abduction and external rotation
- weak contribution to elbow flexion

35
Q

C6 myotome

A

elbow flexion/wrist extension/supination
- internal rotation of shoulder

36
Q

C7 myotome

A

elbow extension, wrist flexion, pronation
- weak contribution to finger flexion and extension

37
Q

C8 myotome

A

finger flexion, finger extension
- thumb extension, wrist ulnar deviation

38
Q

T1 myotome

A

finger abduction and adduction

39
Q

brachial plexus

A
40
Q

origin and spinal nerve root of musculocutaneous nerve

A

C5-7 from lateral cord

41
Q

origin and spinal nerve root of median nerve

A

C6-T1 from lateral and medial

42
Q

origin and spinal nerve root of ulnar nerve

A

C8-T1 from medial cord

43
Q

origin and spinal nerve root of axillary nerve

A

C5-C6 posterior cord

44
Q

origin and spinal nerve root of radial nerve

A

C5-T1 from posterior cord

45
Q

origin and spinal nerve root of long thoracic nerve

A

C5-7 directly from anterior rami

46
Q

origin and spinal nerve root of medial pectoral nerve

A

C8-T1 from medial cord

47
Q

origin and spinal nerve root of lateral pectoral nerve

A

C5-C7 from lateral cord

48
Q

brachial plexus injuries

A

can affect both motor function and cutaneous sensation within the upper limb
- traction injuries may affect either the upper nerve roots or the lower nerve roots of brachial plexus

49
Q

what do injuries to the upper brachial plexus usually result from

A

excessive inc in the angle between neck and shoulder
- may occur in trauma or during birth of a baby if shoulders become impacted in pelvis (shoulder dystocia) and excessive traction is applied to baby’s neck

50
Q

what spinal nerve roots are affected in upper brachial plexus injuries

A

C5/C6 - causing sensory alteration in these dermatomes and paralysis of muscles predominantly supplied by these nerve roots

51
Q

what are the paralysed muscles in an upper brachial plexus injury

A
  • deltoid (axillary nerve: C5-6)
  • teres minor (axillary nerve: C5-6)
  • biceps brachii (musculocutaneous C5-7)
  • brachioradialis (C5-T1)
  • brachialis (musc. C5-7)
  • coracobrachialis (musc C5-7)
52
Q

Erb’s palsy

A

limb hands by side in internal (medial) rotation w an adducted arm and extended elbow; waiter’s tip position

53
Q

injuries the lower brachial plexus

A
  • usually occur due to forced hyperextension or hyperabduction e.g. falling from height and grabs on to branch on way down
  • also if some mechanism of injury is if baby’s arm is delivered first and traction is applied to the arm to deliver the rest of the baby. Injury to the lower roots of the brachial plexus is known as Klumpke’s palsy
54
Q

what nerve roots are affected in lower brachial plexus injuries

A

C8/T1

55
Q

what muscle weakness is affected in lower brachial plexus injuries

A

C8: finger flexion, finger extension
T1: finger abduction and adduction

56
Q

winging of the scapula

A
  • one of the actions of the serratus anterior is to hold the scapula against the ribcage
  • if long thoracic nerve is damaged and SA paralysed, ‘winging of scapula’ occurs
  • medial border of scapula is no longer held against the chest wall so protrudes posteriorly
  • can be clearly seen when the patient is asked to place the palm of their hand on a wall and push; the force is transmitted back along their upper limb to the scapula which ‘lifts off’ the underlying ribs
57
Q

most common cause of winging of scapula

A

trauma
- long thoracic nerve is vulnerable to surgical trauma during a mastectomy w axillary clearance (excision of breast and axillary lymph nodes for cancer) as it passes superficial to serratus anterior muscle in medial wall of the axilla and can be ‘stripped’ along with the axillary nodes and fat
- blunt trauma to the neck or shoulder causing sudden depression of the shoulder girdle, or wearing a heavy backpack

58
Q

what are the 6 groups of axillary lymph nodes

A
59
Q

anterior (pectoral) group

A
  • lying along the lower border of the pectoralis minor behind the pectoralis major
  • receive lymph vessels from the lateral quadrants of the breast and the anterolateral abdominal wall above the level of the umbilicus
60
Q

posterior (subcapsular) group

A
  • in front of the subscapularis muscle
  • receive superficial lymph vessels from the back, down as far as the level of the iliac crests
61
Q

lateral group

A
  • along the medial side of the axillary vein
  • receive most of the lymph vessels of the upper limb (except those superficial vessels draining the lateral side of the upper limb, which drain into the infraclavicular nodes)
62
Q

central group

A
  • in the center of the axilla within the axillary fat
  • receive lymph from: anterior, posterior and lateral groups
63
Q

infraclavicular (deltopectoral) group

A
  • not strictly axillary nodes because they are located outside the axilla
  • lie in the groove between the deltoid and pectoralis major muscles
  • receive superficial lymph vessels from the lateral side of the hand, forearm, and arm
64
Q

apical group

A
  • at the apex of the axilla at the lateral border of the first rib
  • receive the efferent lymph vessels from all the other axillary nodes
65
Q

causes of axillary lymphadenopathy

A
  • Infection of the upper limb - sometimes the infection also causes lymphangitis (inflammation of lymphatic vessels) and red, warm, tender streaks are visible in the skin of the upper limb
  • Infections of the pectoral region and breast
  • Metastases from breast cancer
  • Leukaemia or lymphoma
  • Metastases from malignant melanoma (type of skin cancer) in the upper limb
66
Q

axillary lymph node dissection

A
  • often performed as part of the staging of breast cancers
  • interruption of lymphatic drainage from the upper limb can however result in lymphoedema, a condition whereby accumulated lymph in the subcutaneous tissue leads to painful swelling of the upper limb
  • risk of damage to either the long thoracic nerve (supply to serratus anterior leading to winged scapula deformity) or the thoracodorsal nerve (supply to latissimus dorsi).
67
Q

spinal nerve roots for major brachial plexus branches

A

TRAUMA & ORTHO (11 decks)

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