Back and Spine Pathology Flashcards
Where does the corticospinal tract decussate
Medullary level
How does an upper motor neuron lesion present
Increased tone
Hyperreflexia
No fasciculation
No marked muscle wasting
How does a lower motor neuron lesion present
Decreased tone
Muscle wasting
Fasciculation
Decreased reflexes
What can cause a lower motor neuron lesion
Spinal nerve root injury
Nerve root injury
Or injury to a peripheral nerve
Where do the spinothalamic tracts decussate
Spinal level
What type of sensation does the spinothalamic tract carry
Pain, temperature and crude touch
What type of sensation does the dorsal column carry
Fine touch, proprioception and vibration
Where does the dorsal column decussate
Medullary level
What can lead to acute cord compression
Trauma
Tumours - either haemorrhage or collapse the vertebrae
Infection
Spontaneous haemorrhage
What conditions can lead to chronic cord compression
Degenerative diseases like spondylosis
Tumours
RA
How does a cord transection present
Complete loss of sensation and motor action below the affected level
Initially go into spinal shock - go very floppy
UMN signs appear later
Loss of vasomotor tone below level of damage if the sympathetic chain is interrupted – leads to hypotension
What is the name for a cord hemi section
Brown-Sequard Syndrome
How does Brown-Sequard Syndrome present
Lose dorsal column sensation (fine touch) on the same side as injury but lose spinothalamic sensation (pain/temp) for the opposite side
What causes central cord syndrome
Hyperflexion or extension injury to already stenotic neck
This pinches the cord and the
blood supply which leads to ischaemia in the central portion
How does central cord syndrome present
Predominantly distal upper limb weakness
Very weak hands – strength progressively comes back as you go up the arms
“Cape-like” spinothalamic sensory loss (pain/temp)
Lower limb power and dorsal column sensation preserved
How does chronic cord compression present
Very similar to the acute syndromes
UMN signs predominate
What type of trauma commonly leads to cord compression
High energy injury - car accidents
Falls from height
Mobile portions of spine like the cervical region are most at risk
Which extradural tumours commonly affect the spine and lead to compression
Mets from lung, breast, kidney and prostate
Lymphoma or myeloma
Eat away at the bones of the spine and weaken it
Can present acutely if the vertebrae collapse and suddenly compress the cord
Which intradural tumours commonly affect the spine and lead to compression
extramedullary - meningioma or schwannoma
Intramedullary (in cord itself) - astrocytoma or ependymoma
How can tumours lead to spinal cord compression
Can slowly press on the cord and lead to chronic compression
Can cause acute compression by collapse or haemorrhage
Eat away at the bones leading to a collapse
What can cause spinal canal stenosis
Formation of osteophytes
Disc bulging or prolapse
Facet joint hypertrophy
Subluxation
Which infections commonly cause cord compression
Bloodborne staph - occurs after surgery or sepsis
TB
Both are very rare in the UK
How do you manage a cord compression
Immobilise the patient
Investigate - XR/CT/MRI
Decompress and stabilise - surgery, traction or external fixation
What type of imaging is best if you suspect a spine tumour
MRI
In acute cases what type of imaging is most common
CT
How does spinal traction work
Pulls the spine back into place
Can use a halo with weights
Good for subluxations
How do you treat a spinal tumour
Depends on the patient and tumour
Usually radiotherapy
Mets are usually a sign that the disease is very far gone so often just palliate with radiotherapy
Benign tumours are often excised
How do you treat spinal infection
Antimicrobial therapy
Surgical drainage
Stabilisation where required
How do you treat a haemorrhage that is causing a cord compression
Reverse anticoagulation
Surgical decompression
What is considered chronic back pain
Lasting over 3 months
What is considered sub-acute back pain
lasts 6weeks to 3months
List some degenerative conditions that can lead to back pain
Disc disease Spondylolisthesis Spinal stenosis Facet joint arthritis Scoliosis and other structural issues
List some infections that can lead to back pain
Discitis
Vertebral osteomyelitis
Epidural abscess
Paraspinal abscess
What inflammatory conditions can lead to back pain
Sacroiliitis
Ankylosing spondylitis
Rheumatological conditions affecting the spine
What conditions can refer pain to the back
Aortic dissection
Retroperitoneal disease - pancreatitis
Tumours and abscess
Ovarian disease
List some non-organic causes of back pain
Psychiatric conditions
Malingering - financial or emotional
What other symptoms should you ask about in a back pain history
Weight loss Fever Symptoms in the neck, arms or legs Bladder or bowel problems Cold extremities Non-healing ulcers
What are the red flags for back pain
Acute, rapidly progressive worsening Constitutional symptoms History of malignancy/family history Bladder / bowel Bilateral pain / weakness Pain on lying flat
How does sciatica present
Pain is worse in the legs Sharp and shooting Worse on stretching or standing Better when lying down or knees are bent Painful retention
How does spinal stenosis present
Back pain >> leg pain Brought about by walking Claudication distance Chronic bladder/bowel Gradual bilateral leg weakness
How does cauda equina syndrome present
Back and/or leg pain
Bilateral sciatica
Bilateral leg weakness
Acute bladder/bowel - including incontinence
Painless urinary retention
Perineal/perianal numbness - saddle anesthesia
Impotence
Which drugs can be used for back pain
Paracetamol can be effective
Anti-inflammatory for inflammatory conditions
Muscle relaxants
Amitriptyline or gabapentin for nerve pain
Opiates and derivatives good for acute lower pain
How can you treat back pain
Surgical stabilisation if necessary Keep active - physio and exercise Analgesia Injections - anaesthetic or steroid Proper sitting and lifting advice
How do you manage cauda equina
Must be sent to A&E immediately for assessment
MUST do a PR
Urgent spine MRI
Surgery within 48 hours
Most disc prolapses require surgery - true or false
False
Most get better on their own
This is why patient’s are referred for 6 weeks of physio first
If this doesn’t work then they get an MRI and go on the surgical waiting list
Why is a disc more likely to prolapse to one side rather than centrally
In the centre there is a thicker section of the posterior longitudnal ligament which stops it
