Cervical And Thoracic Spine Injuries

Question 1

What is cervical spondylosis

Answer 1

Chronic degenerative osteoarthritis affection the intervertebral joints in the cervical spine

Question 2

What is the pathology of cervical spondylosis

Answer 2

Primary pathology: age related disk degeneration

Followed by marginal osteophytosis and facet joint osteoarthritis

Question 3

With regards to cervical spondylosis, what is radiculopathy

Answer 3

The narrowing of intervertebral foramina puts pressure on spinal nerves.

Symptoms include paraesthesia, pain and myotomal motor weakness

Question 4

What happens if the spinal canal becomes narrowed in cervical spondylosis

Answer 4

Pressure is put on the spinal cord
Leads to myelopathy: global muscle weakness, gait dysfunction, loss of balance, loss of bladder and bowel control

Due to compression of ascending and defending tracts of the spina cord

Question 5

What is a Jefferson’s fracture

Answer 5

Fracture of anterior and posterior arches of the atlas

Question 6

What is the mechanism of injury for a Jeffersons fracture

Answer 6

Axial leading eg shallow diving

Patient holds head with their hands

Question 7

A Jefferson’s fracture typically causes pain but no neurological symptoms, but what other damage can occur

Answer 7

Damage to arteries in the base of the skull leading t secondary neurological sequelae - ataxia, stroke, Horners syndrome

Question 8

What is Horners syndrome

Answer 8

Damage to sympathetic trunk leading to miosis (decreased pupil size), partial ptosis, anhidrosis (decreased sweating on the affected part of the face) and enophthalmos (sunken appearance of the eyeball).

Assoc with Jeffersons

Question 9

What is hangman’s fracture

Answer 9

The axis vertebrae, through the pars interarticularis

Question 10

What is the mechanism of injury for a Hangman’s fracture

Answer 10

Hyperextension of the head on the neck: - hanging or RTA

Question 11

How can fractures of the Odontoid process on C2 occur

Answer 11

Flexion or extension injuries
Commonly elderly OA patients falling and impacting forehead

Can occur with hyperflexion - falling against a wall

Question 12

How can you detect a fracture of the odontoid process

Answer 12

Open mouth AP X-ray or a CT of the cervical spine

Question 13

What is whiplash

Answer 13

Forceful hyper-extension - hyperflexion injury of the cervical spine

Question 14

The classical mechanism for whiplash is the patients car being stuck from the rear leading to an acceleration injury

Describe the 4 stages:

Answer 14

1) time of impact: vehicle suddenly accelerates forward. 100ms seconds later the patients trunk and shoulders follow, induced by a similar acceleration of the car seat
2) the patients head with no force acting on it remains static in space. This results in forced extension of the neck as the shoulders travel anteriorly under the head. With this extension the inertia of the head is overcome and the head accelerates forwards.
3) the neck then acts as a lever to increase forwards acceleration of the head, forcing the neck into flexion
4) the hyperflexion followed by hyperextension leads to tearing of cervical muscles and ligaments. Secondary oedema, haemorrhage and inflam. Muscles respond to injury by contraction - spasm. The surrounding muscles get recruited to try and splint the injured muscle. The spasm causes pain and stiffness.

Question 15

How can a cervical whiplash injury cause injury to the spinal cord despite the absence of fracture.

Answer 15

Cervical spine is highly mobile
Ligaments ad capsule of the joints are weak and loose.
Get subluxation or dislocation at the time of impact.
May go back to position afterwards with soft tissue swelling being the only evidence on imaging

Question 16

What age group commonly presents with cervical disc prolapse

Answer 16

30-50 yrs

Question 17

Describe the mechanism of disc herniation in the cervical spine

Answer 17

Tear in the annulus fibrosus
Nucleus pulposus protrudes from the disc.
It impinges on a nerve root or the spinal cord

Question 18

What happens when an extruded segment of nucleus purposes separates from the main body of the disc and enters the spinal cord

Answer 18

It gets sequested

Resorted over a period of weeks with resolution of symptoms

Question 19

Why are the crevice exiting nerves more susceptible to impingement than lumbar

Answer 19

There is little space for the exiting nerves so even a smal disc hernitation may impinge and cause significant pain

Question 20

What might a paracentral cervical disc prolapse result in

Answer 20

Impingement of a spinal nerve leading to a radiculopathy

Question 21

What might occur due to a canal filling prolapse in the cervical spine

Answer 21

Acute spinal cord compression

Question 22

In the cervical spine, which nerve root is compressed

Answer 22

Exiting

Question 23

What will a patient with a left sided C5-6 prolapse complain of?

Answer 23

The C6 nerve root is affected.
Paraesthesia in the C6 dermatome - radial border of the left forearm, thumb and index finger.
Weakness in the C6 myotome - left elbow flexion, supination and wrist extension

Pain in the neck radiating down the left arm, often felt over the biceps, into the skin supplied by the C6 dermatome

Question 24

What is cervical myelopathy

Answer 24

Spinal cord dysfunction due to compression of the cord. Caused by narrowing of the spinal (vertebral) canal.

Question 25

What is a common cause of cervical myelopathy

Answer 25

Degenerative stenosis of the spinal canal caused by cervical spondylosis

Question 26

What is cervical spondylotic myelopathy?

Answer 26

Myelopathy (trauma to spinal cord due to compression) CSM is the result of degenerative changes asso with age: Ligamentum flavum hypertrophy or buckling Facet joint hypertrophy Disc protrusion Osteophyte formation Reduction in canal diameter

Question 27

Name some causes of cervical myelathy

Answer 27

``` Congenital stenosis of the spinal canal Cervical disk herniation Trauma’ Tumour RA ```

Question 28

Symptoms of cervical myelopathy are due to compression of the long tracts in the spinal cord. As the canal is 17–18mm in diameter, and the spinal cord is 10 mm, if the diameter falls below 12-14mm, symptoms appear, what are these symptoms

Answer 28

``` Loss of balance and co-ordination Decreased dexterity Weakness Numbness Paralysis ```

Question 29

Patients with UPPER cervical lesions in cervical myelopathy tend to lose manual dexterity and have difficult in writing and non specific alteration in arm weakness and sensation. Patients may also suffer from DYSDIADOCHOKINESIA. What is this?

Answer 29

Impaired ability to perform rapid alternating movvements

Question 30

What do LOWER cervical lesions lead to

Answer 30

``` Spasticity and loss of proprioception in the legs Legs feel heavy Reduced exercise tolerance Gait disturbance Suffer multiple falls ```

Question 31

What dampens spinal reflexes so a person does not over react to stimuli

Answer 31

Long tracts

Question 32

If a patient demonstrates an exaggerated response to stimulation, they may show a positive result for one of two signs, what are these signs

Answer 32

Hoffmans | Babinski

Question 33

Describe the Hoffmans sign and how to test for it

Answer 33

Dr holds middle phalanx of the middle finger. Flicks patients finger nail. No movement in index finger or thumb = test -ve = normal Movement = a positive Hoffman sign and shows that the long tracts are not dampening the spinal reflexes

Question 34

Describe how the Babinski sign is tested for and what it shows

Answer 34

Stroke lateral side of sole of foot with blunt instrument from heel to toes Normally in children the response is FLEXOR - toes plantarflex The babinski sigh it when the hallucinations dorsiflexes and the toes fan out

Question 35

What is L’Hermittes phenomenon

Answer 35

Sensation of intermittent electric shock in the limbs, exacerbated by neck flexion

Question 36

What can happen to a patient in the late stages of severe compression to the cervical spinal cord

Answer 36

Sphincter dysfunction | Quadriplegia

Question 37

What are the commonest causes of thoracic cord compression

Answer 37

Vertebral fractures with bony fragments in the spinal canal Tumours in the spinal canal

Question 38

Where are the most common skeletal sites fir metastases

Answer 38

``` 1 = pelvis 2 = spine ```

Question 39

A metastasis in the T12 vertebrae impinges on the spinal canal and compresses which segments of the spinal cord

Answer 39

L4-5 In the lower thoracic spread and in the lumbar spine the neural segments do not line up as the spinal cord is much shorter than the vertebral column

Question 40

How can pathogens reach bones and tissues of the spine - 3 routes

Answer 40

1) haematogenous 2) Direct inoculation during invasive spinal procedures - lumbar puncture, epidural or spinal anaesthesia 3) spread from adjacent soft tissue infection

Question 41

What is infection of the intervertebral disc called

Answer 41

Spondylodiscitis or discitis

Question 42

What groups of patients are commonly affected by infected discs

Answer 42

Immunocompromised - HIV, DM, patients on steroids

Question 43

Adult intervertebral discs are avascular, so how do organisms get there to infect

Answer 43

Organism initially deposited in the vertebral body Bony ischaemia and infarction Necrosis of the bone= direct spread fo organisms into the adjacent disc space, epidural space and adjacent vertebral bodies

Question 44

Spread of infection into the spinal canal can lead to neurological damage via what 4 mechanisms

Answer 44

1) septic thrombosis leading to ischaemia 2) compression of neural elements by abscess/inflam tissue 3) direct invasion of neural elements by inflammatory tissue 4) mechanical collapse of bone leading to instability, particularly chronic infections

Question 45

What are the most common organisms to infect the tissues and bone of the spine?

Answer 45

Staph aureus Gram -ve bacilli eg e.coli Post invasive op - coagulase negative staph eg epidermidis Pseudomonas and candida seen in iv drug users