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2 MSK Clinical Conditions > Cervical Spine and Brachial Plexus (Session 6) > Flashcards

Cervical Spine and Brachial Plexus (Session 6) Flashcards

1
Q

What is cervical spondylosis?

A
  • Chronic degenerative osteoarthritis
  • affecting intervertebral joints- cervical spine
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2
Q

What is the primary pathology of cervical spondylosis?

A
  1. Age related disc degeneration
  2. Osteophytosis
  3. Facet joint osteoarthritis
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3
Q

What are the symptoms of radiculopathy?

A
  1. Dermal sensory symptoms (paresthesia, pain)
  2. Myotomal motor weakness
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4
Q

How can cervical spondylosis cause radiculopathy?

A
  1. Narrowing of intervertebral foramina
  2. Pressure on spinal nerves
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5
Q

How might myelopathy manifest?

A
  1. Global muscle weakness
  2. Gait dysfunction
  3. Loss of balance
  4. Loss of bowel/bladder control
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6
Q

What is myelopathy?

A

Narrowing of spinap canal puts pressure on spinal chord itself

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7
Q

What’s more common; radiculopathy or myelopathy?

A

Radiculopathy

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8
Q

What is a Jefferson’s fracture?

A

Fracture of anterior and posterior arches of atlas vertebra (C1)

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9
Q

Give 3 mechanisms of injury for a Jefferson’s fracture.

A

Axial loading:

  1. Diving into shallow water
  2. Impacting head against roof of vehicle
  3. Falling from playground equipment
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10
Q

How might a patient present to the emergency department (if they have a Jefferson’s fracture)?

A

Supporting their head with their hands

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11
Q

Why does a Jefferson’s fracture typically cause pain but no neurological signs?

A
  1. Bone fragments ‘burst open’ (like polo mint)
  2. Reduces likelihood of impingement of spinal chord
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12
Q

What complications (damage) can a Jefferson’s fracture cause?

A
  • Damage to arteries at base of skull
  • Can cause:
    • Ataxia
    • Stroke
    • Horner’s syndrome
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13
Q

What is a Hangman’s fracture?

A

Axis vertebrae C2

=fractured trough pars interarticularis

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14
Q

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

A

Forcible hyperextension of head on neck:

  • Eg. road traffic collisions
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15
Q

Why is there a reduced risk of spinal chord injury with a Hangman’s fracture?

A

Like Jefferson’s fracture–>

Fracture configuration expands spinal canal

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16
Q

What is a Peg fracture?

A

Fracture of odontoid process

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17
Q

What is the most commonly seen mechanism for a peg fracture?

A

Flexion/extension

  1. Elderly patient w./ osteoporosis
  2. Falls forwards
  3. Impacting forehead on pavement (hyperextension)
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18
Q

Apart from an elderly patient hyperextending their neck, what is another mechanism of injury for a Peg fracture?

A
  • Blow to back of head
  • Hyperflexion
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19
Q

How can a peg fracture be detected?

A

‘Open mouth’ x-ray or CT scan of cervical spine

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20
Q

What % of the total body weight does the head account for?

A

7-10%

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21
Q

What is a whiplash injury?

A

Forceful hyperextension-hyperflexion injury of cervical spine

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22
Q

What is the classic mechanim of injury for a whiplash injury?

A
  1. Car hit from behind
  2. Cervical muscles and ligaments tear
  3. May be followed by:
    1. Secondary oedema
    2. Haemorrhage
    3. Inflammation
  4. Muscles contract (spasm)- surrounding muscles recruited to attempt to splint injured muscle
    1. –> pain and stiffness caused
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23
Q

What pain/other injuries may patients complain of following a whip lash injury? (3)

A
  1. Arm pain/paraesthesia
  2. Shoulder injuries
  3. Lower back pain (with acute injury in 50% patients)
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24
Q

What is chronic myofascial pain syndrome?

A
  • =Secondary tissue response to disc/facet joint injury
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25
Q

How can a whiplash injury cause injury to the cervical spine?

A

(despite no accompanying bone fracture)

  1. Cervical spine=highly mobile
    1. (ligaments and capsule joints=weak and loose)
    2. therefore, significant movement of vertebrae- subluxation/dislocation
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26
Q

What is the protective factor against spinal chord injury in whiplash injury?

A

Vertebral foramen= relatively large compared to diameter of spinal chord

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27
Q

In what age group does a cervical disc prolapse with assosciated compression of nerve roots or spinal cord most commonly develop?

A

30-50 yrs

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28
Q

In 3 steps, outline the mechanism for disc herniation.

A
  1. Tear develops in annulus fibrosus
  2. Nucleus pulposus protrudes from disc
  3. –> impinges on adjacent nerve root or spinal cord
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29
Q

What happens if sequestration occurs?

  • (Extruded segment of nucleus pulposus separates from main body of disc and enters spinal canal)
A

Rebsorbed over weeks- resolution of symptoms

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30
Q

Why is it that even a small cervical disc herniation can impinge on a nerve and cause significant pain?

A

Little space available for exiting nerves (unlike lumbar spine)

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31
Q

In a cervical intervertebral disc prolapse, which nerve root will be compressed?

A

Exiting

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32
Q

What type of cervical intervertebral disc prolapse would could cause compression of the spinal nerve?

A

Paracentral

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33
Q

What type of cervical intervertebral disc prolapse would could cause compression of the spinal cord?

A

Canal-filling prolapse

34
Q

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

A
  1. C6 affects
  2. Parasthesia in left C6 dermatome
  3. Weakness in left C6 myotome
    1. Left elbow flexion
    2. Supination
    3. Wrist extension
  4. Pain in neck- radiates down left arm into skin supplied by C6 dermatome
35
Q

What is cervical myelopathy?

A

Spinal cord dysfunction

    • due to compression of spinal cord
    • due to narrowing of spinal (vertebral canal)
36
Q

What is the most common cause of cervical myelopathy?

A

Degenerative stenosis

  • caused by cervical spondylosis
  • due to degenerative changes w./ age
    • eg ligamentum flavum hypertrophy
    • facet joint hypertrophy
    • disc protrusion
    • osteophyte formation

(most commonly affects 50-80 year olds)

37
Q

Other than cervical spondylosis, name some other causes of cervical myelopathy. (6)

A
  1. Congenital stenosis (often asymptomatic until adulthood–> when age-related secondary degeneration begins)
  2. Cervical disc herniation
  3. Spondylolisthesis (anterior slippage of vertebral body on vertebra below)
  4. Trauma
  5. Tumour
  6. Rheumatoid arthirits
38
Q

What is the normal diameter of the spinal canal? At what diameter may myelopagthic symptoms begin?

A

Normal= 17-18mm

Spinal chord in cervical region= 10mm

Myelopathic= 12-14mm

39
Q

What is the classic patient presentation of cervical myelopathy?

A
  • Poor coordination
  • Decreased dexterity
  • Weakness
  • Numbness
  • Paralysis (severe cases)
  • Pain
  • Deterioration of gait/hand function (older patients)
40
Q

Specifically, upper cervical lesions tend to cause what symptoms?

A

Loss of manual dexterity

  • Eg. Difficulties writing

Dysdiodochokinesia

  • Impaired ability to perform rapid alternating movements
41
Q

Specifically, lower cervical lesions tend to cause what symptoms?

A

Spasticity

  • Increased muscle tone

Loss of proprioception in legs

Legs feel heavy, reduced exercise tolerance

Gait disturbance

Falls

42
Q

How is Hoffman’s test carried out and what does it show?

A
  1. Doctor holds patient’s middle finger at middle phalanx
  2. Doctor flicks finger nail
  3. If no movement in index finger/thumb
    1. =Negative (normal)
  4. If movement in index finger/thumb
    1. =Positive (abnormal)

tests reflexes of upper extremities

43
Q

How is Babinski’s sign tested for and what does it show?

A

Lateral side- of sole of foot= stroked

Normal: Toes plantarflex

Babinski sign (positive): Toes fan out- hallux dorsiflexes

(suggests damage to long tracts of spinal chord)

44
Q

What is L’Hermitte’s phenomenon?

A

Sensation- intermittent electric shocks in limbs

-exacerbated by neck flexion

(Associated with cervical myelopathy)

45
Q

What complications may occur if surgical decompression is not peformed in the later stages of cervical myelopathy?

A
  • Sphincter dysfunctionn
  • Quadriplegia
46
Q

What is shown in this image?

A

Cervical spondylolisthesis at C3/4

47
Q

If a patient develops myelopathy at the C5 level, what will the likely symptoms and signs will include?

A

Pain: Neck pain

Motor weakness:

  • weakness of shoulder abduction
  • external, lateral rotation
  • weakness of all myotomes distally

Sensory: -paraesthesia from shoulder distally

48
Q

What are the 2 most common causes of thoracic chord compressions?

A
  1. Vertebral fractures
  2. Tumours in spinal canal
49
Q

What % of patients with cancer will have skeletal metastases at death?

A

50-60%

50
Q

What are the 2 most common sites for skeletal metastases?

A
  1. Pelvis
  2. Spine
51
Q

What are the most common cancers that spread to bone? (5)

A
  1. Breast
  2. Lung
  3. Thyroid
  4. Kidney
  5. Prostate
52
Q

If there was a metastasis on the T12 vertebra, which segments of the spinal chord would it compress?

A

L4-5

(Lower thoracic spine and lumbar spine= more compressed)

53
Q

What are the 3 routes by which pathogens can reach the bones and tissues of the spine?

A
  1. Haematogenous (most common)
  2. Direct inoculation- invasive spinal procedures (eg epidural)
  3. Spread from adjacent soft tissue infection
54
Q

What is an infection of the intervertebral disc known as?

A

Spondylodiscitis

Discitis

55
Q

In what group of patients does spondylodiscitis usually occur?

A

Immunocompromised:

Diabetes

HIV

Patients on steroids

56
Q

What is the pathophysiology of discitis?

A
  1. Organisms initally deposited in vertebral body
    1. (since disc=avascular)
  2. Bony ischaemia
  3. Infarction
  4. Necrosis of bone- allows direct spread of organisms into:
    1. adjacent disk space
    2. epidural space
    3. adjacent vertebral bodies
57
Q

What are the 4 mechanims by which the spread of infection in the spinal canal can lead to neurological damage?

A
  1. Septic thrombosis-leading to ischaemia
  2. Compression of neural elements by absess/inflammatory tissue
  3. Direct invasion- of neural elements- by inflammatory tissue
  4. Mechanical collapse of bone- instability
58
Q

What are the most common organims which cause infections in the spinal canal?

A
  • Staphylococcus aureus (50%)
  • Gram negative bacilli (30%) eg E.coli
  • coagulase negative Staphylocci (eg Staph epidermis) (following invasive spinal procedures)
59
Q

What are the mechanisms of injury for injuries to the upper brachial plexus?

A

Excessive increased in angle between neck and shoulder

  • Trauma
  • Birth of baby (shoulders impacted in pelvis)
    • Excessive traction applied to baby’s neck
60
Q

In an upper brachial plexus injury, which movements will be lost?

A

C5:

Shoulder abduction

External rotation

C6:

Elbow flexion

Wrist extension

Supination

61
Q

Which muscles will be paralysed in an upper brachial plexus injury?

A

Axillary nerve:

  1. Deltoid
  2. Teres minor

Musculocutaneous nerve:

  1. Biceps brachii
  2. Brachialis
  3. Coracobrachilais

Radial nerve:

  1. Brachioradialis
62
Q

What is an injury to the upper roots of the brachial plexus known as?

A

Erb’s palsy

63
Q

in what position is the arm held if someone has Erb’s palsy?

A
  • Limb hangs by side
  • Medial rotation
  • Adducted arm
  • Extended elbow

(Waiter’s tip position)

64
Q

What is the name of an injury to the lower roots of the brachial plexus?

A

Klumpke’s palsy

65
Q

What are the 2 mechanisms of injury for Klumpke’s palsy (lower brachial plexus)?

A
  1. Fall from tree- grabs branch on way down
    1. (Klumpke the monkey)
  2. Baby’s arm delivered first- traction applied to pull baby out
66
Q

What motions will be lost in Klumpke’s palsy?

A

C8:

Finger flexion and extension

T1:

Finger adduction and abduction

67
Q

What is the usually deformity which is seen with Klumpke’s palsy?

A

Claw hand

  • Hyperextension of metacarpophalangeal joints
  • Flexion of interphalangeal joints
  • Abduction of thumb
  • Wasting of interossei

(NOT to be confused with high ulnar nerve injury)

68
Q

What causes ‘winging of the scapula to occur’?

A
  • Long thoracic nerve damaged
  • Serratus anterior paralysed
  • Serratus anterior holds scapula in place (usually)
69
Q

What may cause ‘winging of the scapula’?

A
  • Long thoracic nerve acute trauma
  • Blunt trauma to neck or shoulder eg wearing heavy backpack
70
Q

What clinical procedure has a risk of causing long thoracic nerve trauma?

A

Surgical trauma- mastectomy with axillary clearance

Long thoracic nerve passes superficial to serratus anterior muscle

71
Q

What is axillary lymphadenopathy?

A

Enlargement of axillary lymph nodes

72
Q

What might cause axillary lymphodenopathy? (5)

A
  1. Infection of upper limb (lymphangitis)
  2. Infection of pectoral region/breast
  3. Metastases from breast cancer
  4. Leukaemia/lymphoma
  5. Metastases from malignant melanoma of upper limb
73
Q

Why would an axillary lymph node dissection be performed?

A

Part of staging of breast cancer

74
Q

Apart from the long thoracic nerve, what other nerve might be damaged by axillary lymph node dissection?

A

Thoracodorsal nerve (latissimus dorsi)

75
Q

What complication can occur as a result of axillary lymph node dissection (interupting lymphatic drainage of upper limb)?

A

Lymphodema

76
Q

If fractures of the scapula occur, what are they an indication of?

A

Severe chest trauma

77
Q

Why does a fractured scapula not usually require fixation?

A

Surrounding muscles hold fragments in place

78
Q

What are the usual mechanisms of injury of the surgical neck of the humerus?

A
  • Blunt trauma to shoulder
  • FOOSH
79
Q

What are the 2 neurovascular structures at risk of damage in a fracture of the surgical neck of the humerus?

A
  1. Axillary nerve
  2. Posterior circumflex artery
80
Q

Which muscles will be paralysed if the axillary nerve is damaged due to a fracture of the surgical neck of the humerus?

A
  • Deltoid
  • Teres minor\

Abduction lost/weakened

81
Q

What will be the sensory impairment if there is damage to the axillary nerve due to a surgical neck of humerus fracture?

A

Regimental badge area (insertion of deltoid)

2 MSK Clinical Conditions (10 decks)

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