Case 14 Flashcards
1
Q
What shape are babies spine at birth and what is this caused by ?
A
Straight or C shaped from depression in the uterus
2
Q
What are the 3 major functions of the spine ?
A
Movement, support and protection of the spinal cord
3
Q
How does bone growth occur during embryological development ?
A
Centrum and 2 halves of the arch form from mesoderm in utero by week 14.
4
Q
How and when does horizontal and vertebral growth of the vertebrae occur ?
A
Horizontal - periosteal ossification first 7 years
Vertical - sup/inf growth plates first 5 years
5
Q
Name the atypical vertebrae ?
A
C1 (atlas) which rotates around C2 (axis) , C7 (vertebra prominens)
6
Q
What is the difference between sublaxation and dislocation ?
A
Partial discontinuity of joint surface = sub
Full discontinuity = dislocation
7
Q
What is the path of the vertebral artery and vein ?
A
Go through the foramen transversum until C7 when it’s just the artery.
8
Q
What muscle allows tension of the neck, causing it to protrude ?
A
Platysma muscle
9
Q
What vein overlies the sternocleidomastoid ?
A
Jugular vein
10
Q
What structures make up the middle and deep layers of the anterior neck ?
A
Middle - pre tracheal and carotid sheath
Deep - pre vertebral
11
Q
What nerves control the voice box ?
A
Sup laryngeal controls pitch. Recurrent laryngeal controls the rest.
12
Q
What is the muscle that opens the vocal chords and what is its innervation ?
A
Posterior cricoarytenoid muscles
Innervated by the recurrent laryngeal nerve
13
Q
Which nerves have the potential to loop in their path?
A
Median, ulnar, vagus and recurrent laryngeal.
14
Q
What is necessary for venous cannulation and where would it be placed ?
A
internal jugular and subclavian need to be known.
Either between 2 heads of SCM or underneath clavicle (medial 2/3 lateral 1/3) under US guidance
15
Q
What syndrome arises from damage to the sympathetic trunk and what is its triad of sx ?
A
Horner’s syndrome
Myosis (small pupil) , anhydrosis (abnormal sweating, usually seen one half of face) , ptosis
16
Q
At what spinal level do the common carotid arteries bifurcate ?
A
C4.
17
Q
How would you distinguish between thoracic and cervical vertebrae ?
A
Thoracic are larger with larger spinous processes. Flatter vertebral bodies on left side (aorta).
Nerves correspond to vertebrae unlike cervical.
18
Q
How do the different vertebrae articulate with the ribs ?
A
1, 11, 12 articulate solely with named vertebra.
2-10 with rostral neighbour, articulate with anterior transverse process.
19
Q
What is the difference between removing 1 and 5 ribs ?
A
One has little effect on structure and stability
5 leads to disruption of ring so segments of rib suck in during inhalation -> lung can’t inflate.
20
Q
Name the erector spinae muscles and identify which compartment they are in ?
A
Superficial
Iliocostalis , Longissimus, spinalis
21
Q
What compartment are the elevator rostrum and multifidus muscles found ?
A
Intermediate
22
Q
What muscles are supplied by the posterior primary rami?
A
All muscles of the back apart form in the superficial compartment.
23
Q
What is the multifidus ?
A
Intermediate stabilising muscle the originates form spinous process and inserts on mamillary process 1 level below.
24
Q
What structures make up the body of the vertebral disc ?
A
Nucleus polposus, hydrated centre with glycosaminoglycans
Annulus fibrosus, fibrocartiliganous structure with different mesh layers.
25
What adjustments can the doctor/GP impose on a fit note regarding return to work ?
Altered hours, altered activities (eg. less manual labour) , regular breaks (to sit/lie down)
26
When is a fit note required ?
After 7 days off work, prior to this the px can self refer.
27
How long does SSP last ?
Statutory sick pay lasts up to 28 weeks if deemed unable to work.
28
What is health related worklessness ?
People out of work for long term basis (4+ weeks) due to chronic illness or disability.
29
What is the difference between somatic and parasympathetic NS?
Somatic; voluntary motor functioning
| Autonomic; involuntary motor, sympathetic, parasympathetic function
30
Where do the CNs arise ?
```
1-2 = Cerebral hemisphere
3-4 = midbrain
5-8 = Pons
8-12 = medulla
```
31
What is the significance of the nodes of Ranvier ?
Allow for saltatory conduction, large conc of voltage gated Na channels. ^ R to flow elsewhere
32
What is the significance of an 'all or nothing' response during AP production ?
AP always the same size but vary in frequency
33
What is the difference between +/- ions during AP propagation?
+ve cause partial depolarisation (excitatory) so exceeding the threshold is easier
-ve cause hyperpolarisation (inhibitory) so exceeding is more difficult
34
Name two types of summation?
Temporal; lots of APs in short succession build up to depolarisation
Spatial; 1+ at same time so together cause AP
35
What are the functions of LA?
Neuromuscular blockade, good analgesic so decreases pain post op. Stops sensory conduction.
36
What are the possible downsides of LA ? (4)
Toxicity (max dose of LA) causes cardioresp depression, allergic reactions (rare) , vasoconstriction so may miss structures -> possible ischemia (fingers/toes). given IV to reduce risk of cardiac arrhythmias
37
What is often given alongside LA ?
Adrenaline eg. Xylocaine (v weak) , px fells anxious/panic.
38
What is the proper name for Botox and what is it's function?
Botulinum, blocks ACh release. spasticity and hypertonic muscles. lasts about 3 months (hence repeat injections)
39
What the more common of the non depolarising agents used as a neuromuscular blockade ?
Atracurium, blocks synaptic transmitter (post) without depolarising/activating them.
40
What drug may be used as an LA that leads to px twitchy/fits as they're sedated ?
Suxamethonium. Binds to receptor and activates it but has ^ affinity and ^ half life so not broken down by ACh esterase.
41
What is the clinical difference between non depolarising and depolarising agents ?
Non depolarising; competitive antagonist, block action of ACh, not broken down no fasciculation's
Depolarising; single type use, competitive agonist, act in addition to Each, broken down slowly, fasciculations
42
What condition is shown when the px hears everything during a surgery ?
Anaesthetic awareness, px paralysed and 'goes to sleep' no wise but still aware.
43
How can an axon be damaged? (5)
Pressure (compression) , laceration, traction , chemical, thermal
44
What is the Seddon classification of nerve injury?
Normal
Neurapraxia (myelin damage)
Axonotmesis (axon damage within the fibre)
Neurotmesis (whole nerve transection)
45
How would axonotmesis with a lost endoneurium but intact perineum scale on the Sunderland classification ?
grade 3 , loss of axonal continuity no conduction
46
What is the Sunderland classification ?
```
I = neurapraxia, myelin damage
II = loss of axonal conductivity no conduction, with; III (endo lost) and IV (endo+peri lost)
V = nerve trunk divided no conduction (neurotmesis)
VI = mixed, injury varies fascicle to fascicle
```
47
What response is triggered when a fibre is cut ?
Fibre death 4-6 days post injury. Distal to injury macrophages recruited to clear remnants of the nerve fibre including myelin.
48
How does regeneration of fibre occur ?
Regrows proximal -> distal through attraction of nerve fibres (neurotropism) from proximal end. Fibres travel down specific tunnel
49
What happens to motor end plates after damage ?
12-24 months the muscle fibres atrophy. Some function restorable but can disappear even when supply returns.
50
List the anatomical landmarks of the femur from knee to ankle joint ...
```
Physical scar (corresponds to physis)
Metaphysis (proximal)
Diaphysis
Metaphysis (distal)
Physeal scar
```
51
Describe the features of corticol bone
Outer bone ^ density so ^ resistance. Present in longer bones, cells organised into Haversian systems which surround Haversian canal (blood/nerve supply in the centre)
52
What is the other type of bone (apart from corticol) and give some features ...
Trabecular bone, inner spongy ^ metabolic activity. Present in vertebral bodies in spine, wrist, foot
53
What are the components of bone on cellular level ?
Collagen arranged in fibrils for mineral deposition between layers.
Ca/PO4 forms round outside to give strength (hydroxyapatite)
54
What is the non collagenous protein that helps form bone ?
Glycosaminoglycans
55
What is the name of articular cartilage and where is it present ?
Hyaline, joint surface 2-4 mm thick. Thickest in ankle, thinnest around hand.
56
What is the composition of hyaline cartilage ?
H20, collagen (type 2), proteoglycans and sparsely distributed chondrocytes.
57
What is the rate of healing for hyaline cartilage and why ?
Very slow if at all due to a lack of BV supply.
58
What substances form the hydrophilic structure to attract H2O into the gaps in cartilage ? What effect does this have ?
Conjointin and keratin
walking/weight through cartilage squeezes H2O out into space, picks up nutritional elements and brings them back on return
59
What are the 5 main functions of bone ?
Structural support, protection, locomotion, metabolic, haematopoesis (in bone marrow)
60
What is the normal range of free Ca ?
2.2-2.6 mmol/L
61
What do the abnormal levels of Ca lead to?
Hypocalcaemia, channels open spontaneously -> nerve/muscle cells hyperactive -> tetany (muscle spasm)
Hyper, channels shut -> NS function down and deposition of Ca, PO4 (kidney stones)
62
When testing Ca levels what other substance would you test for ?
Albumin to check you're not deficient. If you were this would show less free Ca.
63
Has is dietary Ca distributed throughout the body ?
200mg enters CSF (absorption in duo and upper jejunum). Kidney excretes Ca in urine. Majority out through faeces
64
What does an hour of sunlight produce and what is it then converted to ?
Produces 7-dehydrocholesterol which is converted to Vit D
65
How is inactive Vit D activated ?
Converted in the liver to 25-0H-Cholecalciferol then goes to kidney -> 1,25-di-OH-cholecalciferol
66
What are the two major functions of activated vit D ?
Stimulates absorption of Ca in the intestines
| Stimulates osteoclast function in bone
67
What is the homeostatic mechanism induced when Ca levels drop?
Recognised by the parathyroid which secretes PTH.
Stimulates hydroxylation ^ Ca reabsorption in the kidney and ^ PO4 urine excretion (this frees up more Ca)
Stimulates osteoclast function in bone
68
When are where is Calcitonin released and what is its function ?
Secreted when Ca ^ from C cells in the thyroid. Inhibits osteoclasts so Ca down.
69
What is primary hyperparathyroidism ?
Enlargement in 1+ parathyroid glands. PTH hyper secretion -> Ca ^ -> adenoma (benign)
70
What are the sx of primary hyperparathyroidism ?
Bones, Stones (renal/kidney) , groans (abdo pain) , moans (psych disturbance/depression)
71
Px recently had surgery, presents with tetany and paraesthesia around mouth/feet. What's wrong ?
Hypoparathyroidism, injury to parathyroid glands usually from surgery. Ca down with assoc problems; muscle spasm, tetany (hypocalcaemic).
72
What are osteocytes and how are they formed ?
Cytoplasmic processes that extend through matrix in canaliculi. They are from osteoblasts that remained in newly formed osteoid.
73
How are strains/microfractures detected in bone ?
Canaliculi break so dendritic process is disturbed. Osteocytes transmit info to induce remodelling and repear.
74
What immediate response immediately post fracture helps give structural stability for new bone ?
Inflammation last several days. Bleeding -> inflammation and clotting at site.
75
How is a new haemotoma formed ?
^ Capillary permeability allows ^ local inflammatory mediators -> differentiation/proliferation of stem cells -> new bone formation and repair
76
What are the inflammatory mediators that are attracted to damaged site in bone healing?
IL, IGF, hormones
77
When does bone production start ?
Clotted blood from inflammation replaced with fibrous tissue and cartilage (soft callus)
78
What is the function of soft callus and what process does it undergo ?
Bridges gap from break periosteally and intramedullary. Undergoes ossification -> hard callus , takes weeks.
79
What fx promote healing of bone ?
Good blood supply, mechanical stability, once adequate weight bearing ^ remodelling
80
What fx inhibit healing of bone ? (4)
malnutrition (callus drops) , smoking (inhibits osteoblasts, nicotine -> vasoconstriction so blood supply down) , diabetes (collagen content down, defective cross linking) , infection
81
What is primary bone healing ?
analogous -> bone remodelling in non fractured bone. no callus, bones put together with micro screws. Short length reduction. difficult to monitor.
82
What is osteoporosis ?
Decreased bone mass and micro architectural deterioration of bone tissue -> ^ bone fragility and ^ fracture risk.
83
What are the risk fx for OP? (7)
Age, gender, gentics, lifestyle, low BMI, physical inactivity, Oestrogen down post menapausal.
84
What are the causes of OP ?
imbalance in remodelling bone resorption > bone production. Trabecular bone down so loss connectivity between adjacent bone plates -> ^ fracture risk.
85
How would you diagnose OP and in which site ?
BMD using DEXA scan (dual energy X-ray absorptiometry usually on hip bone.
86
What is the difference between a Z and T score for bone mineral density ?
Z is matched for age, gender and ethnicity
| T score = healthy 30 y/o (gender and ethnicity matched)
87
When are the T and Z scores used for bone mineral density , what are the parameters ?
Z used for non post menopausal women
| T, everyone else. Need to be >2.5 SDs below T
88
What is osteopenia and how is it indicated on bone mineral density charts ?
Area between bold (normal) and dotted (OP) line. indicates 'pre' OP
89
What is the first line drug tx for OP? give 3 examples and the MOA ?
Bisphosphonates; Alendronate, Ibandronate, Risedronate. Decrease bone breakdown to inhibit osteoclast function and induce apoptosis of osteoclasts.
90
What drug tx for OP is used less than bisphosphonates and why ?
PTH analogues (eg. Teriparatide). Varying effects and expensive.
91
What is the MOA of Teriparatide ?
^ bone formation through ^ osteoblast activity
92
What is osteomalacia and what are the key features ?
Vit D deficiency leads to Low Ca poor mineralisation. Decrease Ca/PO4 so new osteoid can't be mineralised. Bones go softer and ^ pliable so more prone to deformation/fracture.
93
What are the causes of Vit D def? (6)
lack of sunlight, poor diet (lactose, vegan) , malabsorption (SB resection, CF) , medication (rifampicin phenytoin) , poor levels in breast milk , abnormal metabolism (liver/renal disease).
94
What are the tx for Vit D deficiency ?
oral D2/3 (requires renal function) eg. Fultium D3, Caloichew D3 forte , 600-2000 IV vit D daily maintenance.
Oral 1-alfacalcidol (longer half life, less demand on kidney)
95
What disease is characterised by disorder bone metabolism; osteoclast overactivity followed by compensatory osteoblast activity
Paget's disease. Disorded woven mosaic bone that's weaker than normal
96
What are the direct sx of Paget's disease ?
Bone pain (deep, constant boring, worse on weight) , patho feature, sarcomatous change
97
What fx of Paget's are described as indirect?
^ CO, compression affects (depends on site)
98
What are the tx for Paget's disease ? When would you tx ?
only when symptomatic, in danger of nerve compression, around a weight bearing joint.
Risedronate; 30mg/day for 2 months
Zoledronate; 5mg x 1 infusion
99
What are the cancers which may metastasise to the bone ?
Breast, kidney, Thyroid, Prostate, Lung
100
How do you class metastasis ?
Lytic (destructive) , sclerotic (^abnormal bone formation) or mixture of both
101
What chemical changes are seen with Osteomalacia ?
decreased Ca and PO4 (decreased Vit D, bones more likely to break)
Normal or high, Alk Phos and PTH (unaffected, may ^ to try and ^ Ca)
102
Can osteoporosis be diagnosed using biochemical tests ?
No , all the tests should be in the normal range
103
What biochem marker would ^ in Paget's disease ?
Alkaline phosphatase
104
What condition is indicated by; ^ Ca, normal PO4 and Alk Phos, ^ PTH ?
Primary hyperthyroidism
105
What biochem changes are seen in renal osteodystrophy ?
Low/normal Ca
| increased ; PO4, Alk Phos, PTH
106
What is the cause of secondary hyperparathyroidism ?
Chronic decrease Ca from renal dysfunction.
107
Goals of spinal trauma ? (5)
Protection, detection, optimise conditions for neural recovery, maintain/restore spinal alignment (decrease loss of spinal motility), rehabilitation.
108
How many people should you have for transfers during spinal cord injury ?
6 but minimum 4 for log rolls
109
How do you mobilise the spine ?
Triple immobilisation
Born keeps spine straight for lifting
Blocks stop head movement side to side
Neck brace fixes the position and allows for access to airway.
110
What is the downside of being on the board for too long ?
Pressure sores
111
What conditions do you have to be aware of when using a bord ?
Ankylosing spondylitis, straightening the spine causes more damage
112
How would you assess an SCI in an unconscious px ?
Flaccid areflexia, diaphragmatic breathing, pain response above clavicle, bradycardia/hypotension, priapism
113
What is shock ?
State of inadequate organ perfusion and tissue oxygenation
114
What are the types of shock ? (8)
Hypovolemic, haemorrhage or fluid loss, tension pneumothorax, cardiac tamponade, cardiogenic (less blood) , neurogenic, septic (BP down) , anaphylactic
115
What are the characteristics of spinal shock?
flaccid paralysis, lack of sensation 2ndry to physiological spinal cord 'shut down'
116
How does spinal shock normally resolve ?
Usually within 24 hours when reflex arcs caudal (post/tail of body) to injury return.
117
What is the characteristic feature of neuro shock and what are the other presentations ?
Bradycardia from decreased cardiac stimulation. Decreased sympathetic outflow (T1-L2) with resultant unopposed vagal tone. Hypotension from loss of BV tone with venous pooling.
118
What is clinical instability of the spine ?
Loss of ability of spine under physiological loads to maintain displacement pattern so there's no neuro deficit, deformity or incapacitating pain
119
When is an erect X ray used ?
normally done in collar. after a CT showing 'stable injury' checks for development of load bearing deformity and ligament injury.
120
When is a dynamic X ray used ?
done 2 weeks post injury check for stability or after tx in collar to check for instability. Flexion and extension x rays taken.
121
What is SCIWORA ?
Without radiographic abnormality; no fragment, no ligament injury, no extra neural compression.
Oedema, concussion, haemorrhage, infarct, transection
122
What are the consequences of untreated SCI?
Paralysis, inadequate ventilation, abdo evaluation compromised, occult compartment syndrome
123
How would you manage hypotension clinically ?
Assume haemorrhage shock until proven otherwise, consider neurological problems, monitor urine output
124
What is autonomic dysreflexia ?
distention of bladder causes ^ impulse to spinal cord -> ^BP, seizures, inter cranial bleeds/stroke
125
How is autonomic dysreflexia triggered and what are the sx ?
Sustained stimuli at T6 or below triggers occurrence at T6 and above.
^BP, red face, HR down, sweating, vasodilation above injury and vasoconstriction below; pale cool no sweat
126
What is the chemical cause of autonomic dysreflexia ?
Chemical cause BV constriction -> ^BP (baroreceptor detection). Brain; parasympathetic (vagus nerve) to slow HR, sends down spinal cord to open BV but cord injury stops messages so not enough to overcome constricted vessels to BP ^
127
What is the tx plan for px with autonomic dysreflexia ?
Monitor BP frequently (systolic 90-110) , sit px up and lower legs, check catheter.
128
What are you checking for in the catheter with autonomic dysreflexia ?
kinks, folds, obstructions, placement. If blocked irrigate bladder with 10-15 ml. if fails remove and replace.
129
What do you do if the systolic bp ^ in a px with autonomic dysreflexia ?
Give GTN to decrease BP and morphine for pain relief.
130
When is GTN spray contraindicated ? What would you give instead and through which route ?
If px on PDE5 inhibitors (viagra, Cialis, levitra) in the last 24 hours.
Nifedipine 10 mg sublingual or crushed tablet under tongue.
131
What is the difference between spondylolithesis and spondylolysis ?
Spondylolithesis, spine slips forward so compensate by curving spine
Spondylolysis, defect or stress fracture in the pars interarticularis (between sup/inf articular facets).
132
What is the common predisposition to spondylolysis and what is the major tx method ?
Certain sports; gym, divers, cricketers
| Non operative conservative
133
How does spondylolithesis present ?
Developmental/acquired. Can be asx but common; LBP, buttock, thigh, groin
Numbness/weakness L5-S1
134
What are the indications for surgery with spondylolithesis ?
Failed conservative management, high grade slip in immature px, neuro compromise
135
What are the characteristic features of Scoliosis ?
Normal kyphosis becomes flat, ribs prominent on one side posteriorly. Vertebral body moves toward convex side, ribs pushed lateral and anteriorly
136
What are the cause of Scoliosis ?
Commonest = idiopathic
| Tumour, syndromes, neurofibromatosis, CT disorders (Marfans, Ehlors danlos) , infection
137
What is the root of Scoliosis ?
Congenital; failure of formation, segmentation or both. Block vertebra from failure to segment. No growth plates on one side and/or too many on other requires early operation (2-3 yo)
138
What are the indications for surgery with Scoliosis ?
Curve >40 immature or >50 mature , relentless curve progression , cardiopulmonary complications , prevent neurological deterioration
139
Why is it important to avoid cardiopulmonary complications in px with Scoliosis ?
Alveoli develop up to 9 yo so a spinal (chest) deformity limits lung function.
140
What is the diagnostic criteria for Scheuermann's kyphosis ?
5 degree ant wedging of 3 contiguous vertebral bodies. Possible end plate irregularities. More common in boys.
141
What is stenosis and where can it arise ?
'Narrowing of a tube'. Can be central, lateral recess (as nerves leave spine) , aorta, gut, spinal canal.
142
What is Claudication ?
Cramping in legs due to exercise, causes the px to limp
143
What is spinal Claudication ?
As you stand up, lordosis ^ and canal narrows. Leaning forward ^ canal. Slippage of one bony ring causes narrowing -> obstruction of subarachnoid space (CSF)
144
What is the result of narrowing of subarachnoid space in spinal claudication?
^ endoneural pressure; compartment syndrome in nerve roots and conduction disturbances
145
Why are sx of; pain, numbness, weakness seen in spinal claudication ?
Arteries can pump blood in but veins can't drain it out -> enlarged swelling and nerve dysfunction
146
How do spinal and vascular claudication vary? (8)
Spinal; pain when standing/walking with relief when sat. Proximal to distal. Worse down hill better ^. Unlimited cycling. Weakness on exertion. Shopping trolley +ve. Normal pulses.
Vascular - the opposite.
147
What investigations would you run for spinal claudication ?
MRI (1st) , erect XR, CT, CT pyelogram
148
What are the serious causes of back pain?
ATIT
Abdo/retroperitoneal cause; AAA, pancreatitis, malignancy
Spinal; Trauma, infection, tumour
149
What are the commenest; tumour in bone, primary tumour in bone, bone tumour ?
Tumour in bone = metastases
Primary tumour in bone = myeloma
Bone tumour = osteosarcoma
150
What are the subclasses for primary tumours ?
Spinal column; benign and malignant
Extradural
Intradural; extra medullary and intramedullary
151
How are spinal metastases classed ? Name the other class apart from primary
Secondary tumours
| Haematological; lymphoma, plasmacytoma, myeloma
152
What are the red flags that indicate an urgent referral is required ? (15) sorry lol
Age extremes (<16 or >50) with new onset pain , past hx of cancer, resent illness/infection, pass steroid use, unexplained weight loss/fevers, end stage Renal disease, OP, Paget's, alcohol/drug abuse, widespread neurological deficits, non mechanical pain (esp at night) , thoracic pain, spinal deformity, hx of significant trauma, fails to improve with tx.
153
What are the common sites of primary tumour in order ?
Breast > lung > idiopathic > Prostate > lymphoma > kidney > myeloma
154
What are the 3 main ways in which metastases spread ?
Bloodstream/lymphatics; thoracic - breast via azygous or lung via segmental arteries. Lumbar - prostate via pelvic venous plexus
Batson; paravertebral and venous plexus
Direct spread
155
What is the time period for spinal cord compression ?
Not dealt with within 24 hours -> paralysis. Compression by bone or tumour mass through patho fracture
156
What are the primary components that need to be assessed when looking for spinal cord compression on physical exam ?
Breast, prostate, lymph nodes, spleen, clubbing
157
What are the time scales for different presentations of MSCC and why ?
metastatic spinal cord compression with neurological signs and sx = urgent referral MRI within 24 hours
Without neurological signs/sx = within 1 week of suspected diagnosis
158
Why is there not much point in operating past 24 hours with MSCC?
Cord ischemia -> nerves die -> intractable pain
159
When is the use of steroids indicated for spine ? What drugs are given ?
Reducing oedema.
| 16 mg Dexamethasone daily, load then 8 mg bd. Can reduce the size/dissolve lymphomas
160
When are steroids contraindicated and what would you have to do when you issue them?
Not given in trauma (would need too ^ a dose)
| They cause GI bleeds so give PPI alongside.
161
What is embolisation ?
Blocking off blood supply to a tumour to decrease the blood loss
162
What is an 'En bloc' ?
Removes whole vertebra. Release disc and cut nerve roots leaving spinal cord. Decreases the recurrence of primary tumour
163
What is the likely distribution of spinal infections and why ?
Just due to size of the vertebrae
| Cervical = 15% , Thoracic = 35% , Lumbar = 50%
164
What are the most common spinal infections ?
Staph aureus / staph epidermis 60%
| Enterobacter 30%
165
What are the 3 methods of spinal infection spread ?
Haematogenous (venous/arterial) , contiguous (touch) , direct implantation
166
What is the difference between a pyogenic and Granulomatous infection ?
Pyogenic is fever forming and is much more common. Looks bad on MRI (easier to tx, just infection)
Granulomatous is Tuberculosis and doesn't involve the disc. Looks good on MRI (harder to treat)
167
What drug tx would you give for spinal infection ?
At least 2 abx with high penetration because they must penetrate the bone and have a long enough half life
168
What is the triad of sx for epidural abscess ?
Pain, fever and neurological sx
169
What is known as the 'red god white plague' disease ?
TB, white inside tumour and px cough up blood. Can reverse paralysis if TB is treated.
170
What is required during abx tx ?
Last min 6 weeks , test inflammatory markers every 2 weeks
171
What are the commenest causes of SSIs in order ?
Surgical site infection
| Staphs areus > Coag neg staph > enterococcus > E coli > pseudomonas
172
What are the endogenous sources of SSIs?
Px flora (skin , membranes, GI tract). seeding from distal focus infection
173
What are the exogenous sources of SSIs ?
Surgical personal (soiled tire, aseptic technique, hand hygiene) , OR environment and ventilation, tools/equipment/materials/implants
174
What are the clinical uses of lumbar puncture ? (3)
Diagnosis of ; meningitis, subarachnoid haemorrahae, inflam CNS disorders
Relive pressure (in hydrocephalus)
Injections of drugs; abx, analgesia, chemotherapy
175
What is the vertebral level of lumbar puncture and why ?
Between L3/4 or L4/5
| The spinal cord ends at L1/2 so this avoids potential paralysis
176
What are the 3 ligaments involved in lumbar puncture ?
Supraspinous (tough)
Interspinous
Ligamentum flavum (^R then give)
177
How should the px be positioned during LP and why ?
Should be fully flexed in left lateral position, transverse space between spinous processes and laminae of adjacent vertebrae is largest.
178
What are the contraindications of LP? (6)
Infection, blood coagulation, drugs, evidence of; intracranial space occupying lesion, ^ intracranial pressure, spinal cord compression
179
How do you avoid dural headache and what is it caused by?
Decrease pressure post lumbar puncture
| Use the smallest possible needle so there's is limited disturbance
180
What side effects are worse sitting up but relieved by lying flat ?
Leak of CSF, decreased CSF pressure, traction of meningeal BVs and CNs
181
What is the equipment required for lumbar puncture ? (9)
Sterile towel, cleaning solutions, some swabs, a manometer (for pressure) , spinal needle, LA solution, needles for infiltration, syringes, sterile bottles for culture and cell/biochem analysis)
182
How do you identify the site of LP ?
Find the PSIS and go 1 vertebral level between an imaginary line between the two. Ensures L3/4 or L4/5
183
What is first injected into the px during LP?
1% Lidocaine with small needle, wait 3 mins to take effect
184
What size needle should be used during lidocaine injection ?
Small orange or grey (22-24 SWG)
185
What needle is required when infiltrating the deeper tissues ? What is necessary before each injection of LA ?
18-20 SWG (green or blue)
| Aspirate before each injection
186
What angle should the spinal needle be inserted ? When will the resistance change and why ?
Insert at 90 degrees
| ^ resistance through the ligamentum flavum with a decrease once in epidural space.
187
How will you know if the needle is in the correct position during LP ?
When the trocar is withdrawn there will be leakage of CSF
188
How much CSF is required for diagnosis and how is it sampled ?
Collected in at least 3 sterile containers with a few ml in each.
189
When do you measure the CSF pressure on the manometer ?
Once CSF pressure has stopped rising up the tube (level will oscillate gently with respiration).
190
What is the procedure once the needle is withdrawn ?
Pressure applied to puncture site with sterile gauze swab for at least 2 mins.
Apply a sterile dressing / plaster to the puncture site
191
What is the process for after a LP ?
Check Px regularly, lie them flat for 30 minutes.
Safely dispose of sharps, label specimens, microscopy and culture (microbiology) protein and glucose (biochemistry) analysis
192
How does an XR work and which structures appear which colours and why ?
White film, X rays hit the film -> black. Bone is most dense (white, most absorption) with fat/soft tissue less dense (greyish). Spinal cord not seen
193
What are the contraindications of XR ?
Cauda equina (cord gets compressed) , chronic LBP , Spinal cord pathology
194
What are the key features of cervical vertebrae ?
Large vertebral foramen. Transverse foramen for the vertebral artery.
195
What is the pathway of the vertebral artery?
Gives post circulation to the brain, artery branches off from the aorta
196
What is the difference between C6 and C7?
C7 has a more prominent spinous process (vertebra prominens) that can be palpated.
197
What does the trachea look like on XR?
Shows as air filled / black because the rays go through it
198
Where are the spinous processes seen on an XR?
Spinous processes point downwards so densities are from the previous process eg. C4s is seen on C5.
199
What is the uncovertsebral joint ?
lateral aspects of the body of cervical spine that give stability to spine and lateral movement between C3 and C7
200
What is the normal Atlas Dens interval and what is the range for pathology ?
Should be around 3 mm but if more than 5 it's abnormal indicating misalignment
201
What is the imaging checklist ?
Name, age, date, type of radiograph.
Adequacy (C7/T1 junction visible excludes abnormality in cervical spine)
Bone, Cartilage, Dens, Extra axial soft tissue
202
What are the vertebral discs made of and how are they affected by age ?
Made of fibrous tissue and H2O which decreases with age. Leads to decreased height which can be seen on XR
203
What happens during a C1 break?
C1 break occurs in 2+ places -> falls apart. lateral muscles fall off edge or alignment issues arise
204
Which area of the spine has the most common cause of sx ?
Lumbar because it's the most weight bearing. It has more mobility and moving parts so is more likely to be damaged.
205
What is significant about the pedicles on XR?
Should look like an owl and if 'winking', indicates a pathology e.g. malignancy (most common site of mets)
206
When does C1 become visible on XR ?
After 1 year, under 6 months it's invisible
207
When do the spinous process synchondroses fuse ?
After 3 years , they open after 6 months.
208
When do the secondary degree ossification centres spinous process tips form and fuse ?
form between 12 and 14 years. Fuse after 25 years
209
Where is the ossification centre for C1?
Post arch, common to not fully fuse so looks like a fracture but is actually just dead centre.
210
How would AK be viewed on an XR and what fractures are common ?
Ankylosing spondylitis can look like a 'bamboo spine' on XR
| Chalk fractures can occur where the spine becomes stiff and snaps.
211
What are the advantages of CT imaging ?
360 rotating tube so can see any plain, 3D imaging, v good spatial and contrast resolution, fast to take (5s)
212
when are CTs contraindicated ?
Contrast allergy, pregnancy (radiation to fetus) , high dose radiation so consider risk of CT v risk of cancer
213
How are MRIs recorded and what does this mean in terms of radiation ?
Uses absorption and emission of radio frequency energy from Hydrogen using magnetic fields and radio waves. Therefore there's no radiation.
214
What are the contradictions of MRI ?
Claustrophobia, Pregnancy, Have to stay immobile (young kids etc) , contrast allergy/renal failure if using Gadolinium
215
What are the different sequences for MRI ?
T1, fat dark fluid dark
| T2, fat dark fluid light
216
How can you change the representation of fat on an MRI and why would you do this ?
```
Saturate the fat to darken/hide it
Shows fluid (pus, inflam, fluid, blood) more easily
```
217
What is Scintigraphy and what is the name of the Tracer used ?
Px injected with radioactive Tn99m which sticks to bone that is more metabolically active (cancer, infection, inflam, fracture). Then detected by a gamma camera
218
What is a myelogram ? When is it contraindicated ?
contrast injected into subarachnoid space under XR (fluoroscopy) then CT scan
Allergy to the dye is a contra
219
What is a DEXA scan and when is it used ?.
Dual energy XR absorptiometry. Measures bone mineral density in the hip. Produces data to guide diagnosis and tx for OP. Low radiation
220
What is a fascicle ?
Bundle of fibres within perineurium (coarse CT)
221
What is the structure of a nerve ?
Bundle of fascicles within epineurieum (tough fibrous sheath) seen in spinal nerve roots. Has thicker artery so less likely injury
222
When does the spinal cord terminate ?
L1/2 in adults, L3/4 in kids
223
What is the conus medullaris ?
Tapered portion of spinal cord. Filum terminale (fibrous band) and cauda equine arise from it
224
What are the sympathetic nerve roots ?
Rami communicantes T1 -> L2
225
What are the parasympathetic CNs and what vertebral level are they at ?
CNs 3, 7, 9, 10
| S2, 3, 4
226
where are the grey columns of spinal cord located ? name them ?
Centrally
| Anterior , Lateral and posterior Horn
227
What is the difference between the Anterior and Lateral horn ?
Ant has alpha, gamma (small neurones) with cell bodies motor fibres going to trunk and limbs
Lateral horn is the sympathetic innervation
228
What is the function of the posterior horn
Sensory.
1+2 partially laminated, nocicpetion, temp, itching
3+4 mechanical pressure
5+6 nociception, proprioception.
229
What is the 1st and 2nd order relay for the posterior horn ?
1st - cell bodies in sensory fibres in DRG
| 2nd - cell bodies sensory relay goes to brain
230
What are the white columns and what are their functions ?
Periphery
Dorsal; vibration, proprioception and discriminative touch
Anterolateral; pain, light touch, temp, pressure
231
What is the function of the anterior spinal artery ? Where does it arise from ?
Supplies the anterior 2/3 of cord. Single artery arises from each vertebral artery at foramen magnum.
232
What is the function of the posterior spinal artery ? Where does it arise from ?
Supplies post 1/3 of cord. Arise at foramen magnum from post inf cerebellar arteries. Lies ant+post to poster rootlets
233
What is the supply of the grey and white posterior columns ?
The posterior spinal artery supplies the grey (central) and white (peripheral) posterior columns
234
What arteries enter via the intervertebral foramen ?
Radicular (feeder) arteries. Reinforce the ant and post spinal arteries, supply the DRG.
235
What is the largest radicular artery ?
Arteria radicilaris magna, usually at T10 or T11 (artery of Adamkiewicz)
236
Where is the anastomoses of all vessels in the cord ?
Under the Pia mater in periphery of cord
237
What is the pathway of the dorsal column and what does it control ?
Ascends through cauda equina same side of cord decussates at the medulla
Meissner's (light touch) Pacanian (vibration and pressure)
238
Which tract crosses at the cord ? what does it control ?
Spinothalamic so controls opposing side
| Lateral (pain + temp) anterior (light touch and pressure). Goes from spine to thalamus
239
What is the significance of 10% of the corticospinal fibres ?
10% don't cross at the medulla so control function on the same side. originates in cortex (motor signals down to make you move)
240
What is the significance of the anterior horn?
Landmark for lesions. At the level - LMN sx, Below the level - UMN sx. Above the level - normal.
241
What are the classical signs of an UMN lesion?
severe weakness, mild atrophy, tone and stretch reflexes ^ (UMN). Clonus and Plantar reflex
242
What are the classical signs of a LMN lesion
mild weakness, severe atrophy, fasciculations decreased reflexes and tone
243
What is the difference between a primary and secondary spinal cord injury ?
Primary occurs at the time eg. trauma
| Secondary occurs after so is preventable
244
What is a complete SCI ? Why might it be difficult to confirm at first ?
no sensation or voluntary motor function below the level of injury. Can only be confirmed once spinal shock has resolved.
245
How can you tell when spinal shock has been resolved ?
When reflex action has returned. Shows the Na/K pumps are working again.
246
What are the categories for motor function grading ?
0 = nothing , 1 = palpable/visual contraction , 2 = move without gravity (lateral) , 3 = move with gravity (vertical) , 4 = move but R overcomes , 5 = normal
247
Px experiences voluntary rectal tone and great toe movement post SCI, what does this indicate ?
Sacral sparing after the SCI
| intact long tract neurones and potential for recovery
248
What differences are seen in anterior cord syndrome ?
motor, pain, temp loss but with proprioception sparred. bilateral spastic paralysis with some sacral sparing
249
What syndrome shows a loss of proprioception, vibration and 2 point discrimination with motor and pain preserved ?
Posterior cord syndrome. Common in infection, syphilis and tumours in bone.
250
What is Cape distribution and which syndrome is it seen in ?
Affects the upper limbs over the lower limbs due to order of tracts (cervical, thoracic, lateral, sacral). Seen in central cord syndrome (cervical spondylosis)
251
Where are the stages of recovery shown in central cord syndrome ?
Lower limb > bladder > upper limb > sensory. Most common syndrome
252
What is Brown Sequard syndrome ? cause, losses ?
Usually penetrating injury -> ipsilateral paralysis
Same side loss; motor, proprioception, vibration
Opposing side loss; pain temp light touch pressure
253
What is the difference between Gracile and Cuneate fascicularis ?
Grace ; ipsilateral loss of tactile discrimination + position, vibration, sensation from leg
Cuneate is same but in the arm.
254
What occurs during ventral white commissure dysfunction ?
Bilateral loss of pain and temperature. Sensation within dermatomes of involved segments
255
What is radiculopathy ? What are the features ?
Gradual compression of nerve root (LMN). affects 1 lvl unilaterally, loss dermatome sensation, myotome motor weakness, flaccid tone, hypo reflexive, pain and dysaesthesia
256
What are the features of myelopathy?
Gradual compression of spinal cord (UMN) Affects >1 level, bilateral sx, variable sensation, motor weakness, spastic tone, hyper reflexive, broad gait with poor balance
257
If a px presents with a babinski reflex and clonus, what Neuron is affected ?
Upper motor neuron lesion
258
What is clonus and how many 'beats' are considered abnormal ?
inverted radial reflex. reflex on other side triggered from stimulating the other one. 5+ beats abnormal.
259
What are Lhermitte's and Hoffman's signs?
```
Lhermitte's = head back or forward causes pain through whole body
Hoffman's = pain through DIP joint when 'flicking' 3rd finger
```
260
What are the common presenting features of Cauda equina syndrome ? (5)
Spectrum of LBP, uni/bilateral radiculopathy, saddle anaesthesia and motor weakness in lower extremities with variable rectal and urinary sx.
261
What are the causes of Cauda Equina syndrome ?
Canal filling disc compressing Cauda Equina, may be due to tumour / infection / trauma
262
What is the crucial feature of caudal equine syndrome ?
Bladder and bowel / sphincteric disturbance. Take pressure off nerves as quickly as possible and dura will pulsate again
263
What is the tx plan for CES ?
only modifiable fx is time to dx /tx
Emergency MRI -> refer -> Operate (ASAP/safely)
neuro deterioation leads to worse outcome
264
What is the difference between CES-S and CES-I ?
suspected; bilateral radiculopathy, large central disc on MRI -> at risk of CES
Incomplete; objective evidence, impaired perineal sensation, some sphincter problems, retains voluntary control of bladder
265
What is pyrexia and what is it's triad of sx?
^ body temp and fever
| Abscess, pain and neurology
266
What is the posterior muscle that produces extension and stabilises the spine during abdominal contraction?
Iliocostalis
267
Which ligament has the highest elastin content of the ligaments associated with lumbar spine?
Ligamentum flavum
268
How does the nucleus pulpous receive nutrition ?
Through pores in its endplates
269
What is the Loosers Zone
psduofracture that radiologically appears as wide transverse lucency traversing part way through bone
Associated with rickets and osteomalacia
270
Where is CSF withdrawn from during lumbar puncture ?
Sub arachnoid space
271
What does Sunderland 2 damage indicate ?
Nerve compression injury results in loss of axonal continuity in a peripheral nerve but with intact endoneurium
272
Which tract does polio muscular atrophy occur ?
Lateral corticospinal (muscle motor)
273
What structure modulates nociceptive pain through opioid receptors ?
Periaqueductal grey matter
274
What is the most important red flag with back pain ?
Previous hx of malignancy
275
What is the test used to test the S2-4 reflex and what can it indicate ?
Bulbocavernosus reflex, squeeze the glans penis.
| First to return post spinal shock
276
What does parathyroid hormone bind to to initiate resorption of Ca from bone?
Macrophages
277
What structure is secreted by the thyroid gland that inhibits osteoclasts ?
Calcitonin
278
What is the primary cause of osteodystrophy ?
Reduced hydroxylation of Vit D
279
What is the downside in steroid tx for asthmas and arthritis ?
Inhibits osteoblast activity -> reduced bone density
280
What vertebra is most likely to be affected by a compression fracture in px with OP
T12
281
What dermatome is related to the medial and lateral thigh ?
L2
282
What is the function of the quadrates lumborum ?
Helps stabilise the 12th rib during resp and facilitates lateral flexion of the lumbar spine
283
What are the distinguishing features of the cervical vertebra?
Smaller body, foramen for vertebral artery/vein
284
What are the layers of the meninges ?
Endoneurium , perineum and epineurium
285
What are the ligaments of the spine from out to in ?
Supraspinatus , interspinatous, ligamentum flavum , posterior longitudinal , anterior longitudinal
286
What is the name of the supraspinatus ligament above the 7th cervical vertebra ?
Nuchal ligament
287
What are the layers of the intervertebral disc ?
Nucleus polposus on the inside and annulus fibrosus on the out
288
What sensations are lost and maintained during anterior spinal cord syndrome ?
Sx below level of injury; motor , proprioception and vibration lost . Pain and temp kept.
289
Px has a spinal cord lesion that results in loss of pain and temperature below the lesion with motor and proprioception sparing. What is the syndrome ?
Posterior spinal cord syndrome
290
A px gets stabbed on their right hand side at the level of T5. What sensations are lost on the left hand side of their body?
Brown sequard syndrome
Lose pain and temperature on the left hand side
Motor and proprioception on the right are lost.
291
What is sciatica and what is the usual cause ?
Sharp unilateral leg pain with numbness/parathesia in dermatomes of the sciatic nerve. Usually caused by herniated IV disc compressing a lumbar nerve root.
292
What is the purpose of an RCT?
Randomised control trial. Used to evaluate cause and effect of; new meds, tx, healthcare tech, new screening programmes, delivery of new services etc
293
What is the CI and what does it indicate when high and low ?
Confidence interval, validity of results and which test is superior to the other. If high shows results are valid and first is sig Dif to other. If includes 0 then no sig Dif between data sets.
294
What is CNMP and how does it affect mortality ?
Chronic non malignant back pain. Higher all cause mortality
295
What are the time frames for acute, sub acute and chronic back pain ?
Acute <6 wks (but can be 4 wks/3 months)
Subacute 6-12 wks.
Chronic, constant/intermittent for 6 months + (or 3 mths for older adult)
296
How many days is a px allowed to self certify before they need a fit note ?
7 calendar days.
297
What is a px defined as on a fit note ?
Not fit to work (px should refrain from work for period of time)
May be fit to work (px could return to normal work however may not be able to complete normal hours/duties)
298
What are the 4 aspects about what pain means to the px 'belief about pain and illness' ?
Nature of illness (cause/meaning)
Future course (duration/outcome)
Consequences on life/work
Cure or control (expectations assoc with tx)
299
What is the purpose of the fear avoidance model ?
Prevents acute LBP becoming CBP. Helps realise pain perception maintains pain for px.
300
What are the traits of the 'avoider' in the fear avoidance model ?
Gets frightened by pain and worries about future. Worry that hurt will cause further damage (it doesn't). They rest and wait for pain to improve
301
What are the traits of a 'Coper' in the fear avoidance model?
Knows pain will improve, doesn't fear future. Carriers on as normal as possible. Stays +ve active/gets on with life
302
Which trait is better in the fear avoidance model ?
Avoiders suffer more, have pain for longer and take more time off work leads to disability. Copers have less long term damage
303
What are the catergories of 'flags' for LBP mx ?
Red flags; organic path, concurrent medical problem
Yellow (psych fx) flags; beliefs, coping, stress, willingness to change
Blue flags (job) ; fam, work
Black (socio-occupational); work satisfaction/condition. social policy
304
What sx suggest cauda equina syndrome (compression) (4)
Loss of bowel control (faecal incontinence) and laxity of anal sphincter
Loss of bladder control (urinary retention)
Severe/progressive neuro deficit in lower extremities/gait disturbance
Saddle anaesthesia or parathesia (change in perianal sensation)
305
What sx may suggest cancer progression ? (6)
new onset pain >50 , hx of cancer, fail to improve after 1 month. Persistent night pain. Structural spine deformities, unexplained weight loss
306
Px presents with sx of ; fever, chills, rigors, immunosuppression, IV drug misuse, recent bacterial infection, penetrating wound. What is the dx ?
Infection
307
What are the 'red flags' of serious pathology ?
sensory/motor loss, hx of serious injury, px with/at high risk of OP
308
Analgesia options after paracetamol are NSAIDs (ibuprofen) or opioids. What drugs might be needed to be given with each of these ?
NSAIDs; if >45 use a PPI to reduce ulcer formation
| Opioids; give laxative to counteract constipation effect (straining to defecate may aggravate back pain).
309
If at 6 wks the pain has failed to settle, what tx should the px be offered ?
```
Acupuncture (10 sessions over 12 wks)
Manual therapy (spinal manipulation)
Group based exercise (^aerobic, move instruction, muscle strength etc)
```
310
Which areas are linked to; leaning back with pain , pain down the legs when leaning back , leaning forward with pain ?
Lean back with pain ; Facets
Pain down legs when leaning back ; Stenosis (canal narrows)
Lean forward with pain; discs (root gets stretched over disc), musculature of back, sciatica
311
What is the 'Keele STarT' back screening tool ?
Score asess mental capacity for tx.
0-3 low risk; analgesia, signpost, safety net
4+ use sub scoring
312
What is the Sub scoring used when STarT is >4 ?
0-3; med risk. ^vigilance, review, back team maybe needed
| 4+; high risk. ^chronicity, early referral back pain, specialist team.
313
What are Waddell's signs ? (5)
medically unexplained sx of chronic LBP;
superficial/diffuse tenderness, stimulation (movements that produce pain without moving) , distraction , regional weakness/sensory loss, overreaction.
314
5 cardinal signs of inflammation ?
Redness, heat , pain, swelling and loss of function.
| Can also include capillary dilatation and leukocytic infiltration.
315
What is radiculitis ?
Inflammation of the root of a nerve. radiates along dermatome due to inflammation or irritation of nerve root (radiculopathy) at connection to spinal column.
316
What are the stages of pain perception ? (6)
Transduction, transmission, modulation, perception, interpretation, behaviour
317
What are the risk fx for LBP sciatica ? (5)
Previous LBP, smoking, obesity, heavy physical work, psychosocial fx (stress, anxiety etc).
318
What is the REAPRIOP chronic LBP model of tx ?
Reassurance (unlikely to be serious) , Explanation (muscular/age) , Advice (NICE) , Prescription (analgesics) , Referral (physio, exercise) , Investigation (only if indicated) , Observation (follow up safety net) , Prevention (healthy life)
319
What are the red flags for cord compression ?
Going off legs, losing balance, weakness/numbness, CES (urgent referral)
320
Which vertebrae are more prone to herniation ?
L4/5 , L5/S1 are 95% of cases. Most are lateral affecting traversing root.
321
What is the major cause of degenerative disc disease ?
Genetics
