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Neurology > 14. Spinal cord compression (including sciatica) > Flashcards

14. Spinal cord compression (including sciatica) Flashcards

1
Q

The spinal cord runs between which 2 points?

A

Cord extends from C1 (junction with medulla) to L1/L2 (conus medullaris)

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2
Q

What is located below L1?

A

Lumbar & sacral nerve roots - grouped together to form the CAUDA EQUINA

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3
Q

What is the final point of the spinal cord called?

A

Cauda Equina

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4
Q

What is paraplegia?

A

Paralysis of BOTH LEGS ALWAYS caused by spinal cord lesion

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5
Q

What is hemiplagia?

A

Paralysis of ONE SIDE of body caused by lesion of the brain

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6
Q

What are the 3 tracts of the spinal cord?

A
  1. Corticospinal
  2. Dorsal column
  3. Spinothalamic
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7
Q

What does the corticospinal tract transmit?

A

Motor

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8
Q

What is the function of the corticospinal tract?

A

Descending UMN

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9
Q

Where does the corticospinal tract decussate?

A

85% decussates in the medulla, this is the lateral tract
15% decussates in the spinal cord, this is the medial tract

Remember that the corticospinal tract is motor, so impulses travel down from brain to spine.
Thus, the lateral tract is contralateral to the brain, but ipsilateral to the muscles it innervates.

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10
Q

What do the dorsal spinal columns transmit?

A

Proprioception, vibration and 2 point discrimination (fine touch)

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11
Q

Which spinal cord pathway has gracilis and cuneate nuclei?
What are these for?

A

Dorsal spinal column:

  • Gracilis = medial = legs
  • Cuneate = lateral = arms
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12
Q

What tract controls “nice sensations”?
Where does it decussate?

A

Dorsal columns - for touch, vibration, proprioception.

Gracile fasciculus - legs AND cuneatus fasciculus - arms.

Decussate in upper medulla.

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13
Q

Where do the dorsal spinal columns decussate?

A

Medulla

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14
Q

What does the spinothalamic tract transmit?

A

Pain and temperature

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15
Q

Where do the spinothalamic tracts decussate?

A

Spinal cord

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16
Q

If UMN signs are present, where does it indicate the lesions are?

A

Indicate that the lesion is above the anterior horn cell
I.E. in the spinal cord, brainstem and motor cortex

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17
Q

Describe the features of a UMN lesion.

A
  1. Increased muscle tone - spasticity
  2. Pyramidal Weakness:
    - In legs: flexors are weaker than extensors
    - In arms: extensors are weaker than flexors
  3. Increased reflexes, they are brisk - HYPERREFLEXIA
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18
Q

If LMN signs are present, where does it indicate the lesions are?

A

Indicate that the lesion is either in the anterior horn cell or distal to the anterior horn cell
I.E. in anterior horn cell, nerve roots, plexus or peripheral nerve

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19
Q

Describe the features of a LMN lesion.

A
  1. Decreased muscle tone
  2. Muscle wasting (atrophy) ± fasciculation (spontaneous involuntary twitching)
  3. Weakness that corresponds to those muscles supplied by the involved cord segment, nerve root, part of plexus or peripheral nerve.
  4. Reduced/absent reflexes
  5. Hypotonia/flaccidity - limb feels soft and floppy
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20
Q

Define spondyloisthesis.

A

Slippage of vertebra over the one below.

  • Nerve root comes out ABOVE the disc, therefore root affected will be the one BELOW the disc herniation
    e.g. L4/L5 herniation leads to L5 nerve root compression
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21
Q

Define spondylosis.

A

Degenerative disc disease.

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22
Q

Define myelopathy.

A
  • Spinal cord disease.
  • UMN problem + signs r.g. spasticity, weakness, hyper-reflexia.

Caused by spinal cord compression.
Surgery is often indicated to prevent deterioration.

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23
Q

Define radiculopathy.

A

Spinal nerve root disease; LMN problem + signs e.g. decreased muscle tone, wasting, weakness and fasciculations.

Caused by spinal root compression.

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24
Q

Is myelopathy or radiculopathy an UMN problem?

A

Myelopathy is a spinal cord disease and therefore is an UMN problem.

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25
Q

Is myelopathy or radiculopathy a LMN problem?

A

Radiculopathy is a spinal nerve root disease and therefore is a LMN problem.

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26
Q

What is a myotome?

A

A myotome (greek: myo=muscle, tome = a section, volume) is defined as a group of muscles which is innervated by single spinal nerve root

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27
Q

Which myotome does C5 innervate?

A

Shoulder abduction/biceps jerk

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28
Q

Which myotome does C6 innervate?

A

Elbow flexion/supinator jerk

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29
Q

Which myotome does C7 innervate?

A

Elbow extension/triceps jerk

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30
Q

Which myotome does L3/4 innervate?

A

Knee extension/knee jerk

31
Q

Which myotome does L5 innervate?

A

Ankle dorsiflexion (upwards)

32
Q

Which myotome does S1 innervate?

A

Ankle plantar flexion (downwards)/ankle jerk

33
Q

What is a dermatome?

A

An area of skin that is mainly supplied by afferent nerve fibres from the dorsal root of any given spinal nerve.

34
Q

What is the C3-4 dermatome?

35
Q

What is the T1 dermatome?

A

Medial side of the arm

36
Q

What is the T4 dermatome?

A

Nipple level

37
Q

What is the C6-7 dermatome?

A

Lateral arm/forearm

38
Q

What is the T10 dermatome?

A

Umbilical level (Umbilicus)

39
Q

What is the L1 dermatome?

A

Inguinal ligament

40
Q

What is the L2-3 dermatome?

A

Anterior and inner leg

41
Q

What is the L4 dermatome?

A

Knee and ankle
- Parts of the thigh, knee, leg, and foot.

42
Q

What is the L5, S1-2 dermatome?

A

Posterior and outer leg

43
Q

What is the S4 dermatome?

A

Perianal area

44
Q

What would be felt in the myotome and dermatome affected by a spinal nerve root lesion?

A

Myotome - pain of root compression.
Dermatome - tingling discomfort.

45
Q

Define spinal cord compression.

A

Compression of the spinal cord due to processes that compress/displace arterial, venous, CSF spaces and the cord itself, resulting in upper neurone signs and specific symptoms, dependent on where compression is.

46
Q

Does spinal cord lesion affect upper or lower motor neurones?

A

Usually both

47
Q

What is the most common cause of acute compression?

A

Vertebral body neoplasms

48
Q

What is the most common cause of spinal cord compression?

A

Secondary malignancy from lung, breast, prostate, kidney etc.

49
Q

Give 3 causes of spinal cord compression.

A
  1. Vertebral body neoplasm
  2. Cancer (metastatic myeloma, bone tumour, glioma)
  3. Secondary malignancy commonly from lung, breast, prostate, myeloma, lymphoma
  4. Disc herniation
  5. Disc prolapse
  6. Infection e.g. epidural abscess
  7. Haematoma e.g. warfarin
  8. Primary spinal cord tumour e.g. glioma, neurofibroma
  9. Spinal stenosis
50
Q

What are the 3 classifications of spinal cord compression caused by tumours?

A
  1. Intramedullary - in the vertebral canal
  2. Leptomeningeal - where the meninges should be
  3. Extradural - compressing the dura from the outside
51
Q

Give 2 causes of nerve root lesions.

A
  1. Spondylosis
  2. Herpes zoster
  3. Tumours
  4. Meningeal inflammation
52
Q

What part of the spine is most commonly compressed by tumours?

53
Q

If all limbs are affected, where is the spinal cord lesion?

54
Q

If only the legs are affected, where is the spinal cord lesion?

55
Q

If the diaphragm is affected, where is the spinal cord lesion?

56
Q

Clinical presentation of spinal cord compression.

A

Depends on the level of the lesion:
1. Back pain
2. Weakness or paralysis

  1. Sensory loss BELOW level of lesion
  2. LMN signs AT the level of lesion
    (especially in cervical cord compression)
  3. UMN signs BELOW the level of lesion
    -> contralateral spasticity + hyperreflexia
  4. Later manifestation: Bladder (and anal) sphincter involvement
    -> Hesitancy, frequency and later as painless retention
  5. Hypotension and bradycardia (neurogenic shock)
57
Q

Describe the motor impairment in a spinal cord lesion.

A

LMN signs at the level of the lesion – wasting, weakness, hyporeflexia

UMN signs BELOW the level of the lesion – hyperreflexia, contralateral spasticity, extensor plantar reflex

58
Q

How is continence affected in spinal cord lesions?

A

UMN pathology
- Increased sphincter tone
- Retention and constipation

59
Q

Describe the sensory impairment in spinal cord compression.

A

Ascending numbness.
Parasthesia.
1-5 caudal levels below the lesion.
Less common than motor symptoms.

60
Q

How would tibial nerve damage present (L4-S3)?

A

Unable to stand on tiptoe, invert foot or flex toes.

Originates from sciatic nerve just above the knee.

61
Q

How might damage to the lateral cutaneous nerve of the thigh present (L2-L3)?

A

Meralgia paraesthetica - anterolateral burning thigh pain from entrapment under inguinal ligament

62
Q

Give 2 signs of damage to the common peroneal nerve (L4-S1).

A

Foot drop.

Weak ankle dorsiflexion/eversion.

Sensory loss over dorsum of foot.

63
Q

Investigation for spinal cord lesion/compression.

A

MRI of the whole spine - GOLD STANDARD

  • DO NOT DELAY IMAGING, AT ANY COST!!!! - since irreversible paraplegia may follow if the cord is NOT DECOMPRESSED.
  • Speed of imaging should parallel the rate of clinical progression.
64
Q

Treatment of spinal cord compression.

A
  1. IV Dexamethasone ± radio/chemotherapy
  2. Catherisation
  3. Analgesia
    - e.g. epidural steroid injections
  4. Surgical decompression if indicated
    - e.g. remove tumour, discectomy
65
Q

Differential diagnosis for spinal cord compression.

A
  1. Transverse myelitis
  2. Multiple sclerosis (MS)
  3. Cord vasculitis
  4. Trauma
  5. Dissecting aneurysm
  6. Guillain-Barre (GBS)
  7. ALS
66
Q

Define sciatica.

A

Where the sciatic nerve, which runs from your lower back to your feet, is irritated or compressed
-> Leading to pain from the lower back down to the lower leg.

67
Q

Give some spinal causes of sciatica.

A
  1. Intervertebral disc herniation (MOST COMMON)
  2. Poor posture
  3. Trauma
  4. Strong rotational movement
  5. Spinal stenosis
  6. Inflammatory diseases
  7. Malignancy/Abscess
68
Q

Give some non-spinal causes of sciatica.

A
  1. Piriformis syndrome
  2. Wallet sciatica
    - Many people carry a wallet in their pocket
    - As they sit, the wallet puts pressure on the gluteal muscles, which compresses the sciatic nerve → sciatica
  3. Pregnancy
  4. Trauma to leg
  5. Pelvic tumours
69
Q

Clinical presentation of sciatica.

A
  1. Unilateral pain from the buttock radiating down the back of the thigh to below the knee or feet.
  2. Paraesthesia (pins and needles).
  3. Numbness and motor weakness.
  4. Reflexes may be affected depending on the affected nerve root.
70
Q

What is a red flag for cauda equina syndrome?

A

Bilateral sciatica

71
Q

Investigations for sciatica.

A
  1. Physical examination - Sciatic stretch test - Lasegu’s signs:
    - Examiner raises straight leg, which stretches nerve root over the herniated disc.
    - If pain worsens when leg is between 30 and 70 degrees -> sciatica.
    - Symptoms improve with flexing the knee.
  2. CT/MRI of spine - to find the cause.
72
Q

What is the treatment for sciatica without neurological signs?

A

Conservative management e.g. physio and NSAIDs.

73
Q

Treatment of sciatica.

A

Usually resolves on its own over time but the pain can be relieved thorugh use of pain medication:

  1. Analgesia (not opioids)
  2. NSAIDs

If symptoms are persisting or worsening at follow up:
- Amitriptyline
- Duloxetine

Specialist management options for chronic sciatica include:
- Epidural corticosteroid injections
- Local anaesthetic injections
- Radiofrequency denervation
- Spinal decompression

Neurology (20 decks)

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