Cervical spondylosis; Spinal cord compression; bone metastases

Question 1

Define cervical spondylisis [1]

Answer 1

Cervical spondylosis is a term used to describe degeneration of the vertebral column in the cervical (neck) region. It is otherwise known as cervical osteoarthritis.

NB: It’s important to note that cervical spondylosis is a normal part of ageing and many individuals with radiological evidence of the condition remain asymptomatic.

Question 2

Give a brief overview of the pathophysiology of cervical spondylosis

Answer 2

Initial Degeneration of intervertebral disc
- nucleus pulposus loses its water; decrease in disc height
- increased load on the annulus fibrosus, causing it to fissure and tear

Osteophyte formation

Degenerative Changes
- ligamentum flavum and posterior longitudinal ligament calficy leading to spina stenosis

Neural Compression:
- compression of nerve roots

Vasuclar compromise

Question 3

Describe the clinical features of cervical spondylosis

Answer 3

Pain and/or stiffness in cervical region
Referred pain: retro-orbital, temporal, occipital, interscapular, upper limbs.
Signs of radiculopathy (most commonly affecting nerve roots C5 to C7)
* Unilateral neck, shoulder or arm pain, paraesthesia, or hyperaesthesia
* Diminished arm reflexes (triceps: C7, biceps: C5/C6, supinator: C5/C6).

NB - It is worth noting that many patients with degenerative change in the cervical region are asymptomatic.

Question 4

Describe the investigations used for cervical spondylosis [3]

Answer 4

Generally cervical spondylosis is diagnosed clinically

Plain X-ray:
* Osteophyte formation
* Narrowed disc spaces
* Narrowing of intervertebral foramina

MRI

Question 5

How do you differentiate between cervical spondylosis and radiculopathy? [2]

Answer 5

The pain pattern in cervical radiculopathy is typically more localised compared to cervical spondylosis, which often manifests as diffuse neck pain.

Positive Spurling’s test:
- neck extension and lateral rotation towards the symptomatic side exacerbates symptoms

Question 6

How do you differentiate between cervical spondylosis and myelopathy? [2]

Answer 6

Cervical myelopathy:
* UMN lesions - hyperreflexia, clonus, and positive Babinski sign.
* Gait disturbance
* Neurofocal deficits

NB: Cervical Myelopathy results from spinal cord compression and is characterised by signs of upper motor neuron lesion

Question 7

Neoplastic spinal cord compression can be due to: [2]

Answer 7

Metastatic deposits
Primary cancer of the spine

Question 8

Which cancers predominately metastasis to the bone? [3]

Answer 8

Breast (most common)
Lung
Prostate

Question 9

Metastases to the bone are usually via [] spread.

prostate and breast, this is via the [] system
lung cancers usually spread via the [] system.

Answer 9

Metastases usually spread via the blood (haematogenous),

• prostate and breast, this is via the venous system.
• lung cancers usually spread via the arterial system.

Question 10

Clinical features of neoplastic spinal cord compression?

Answer 10

back pain
lower limb weakness - typically symmetrical; progressive - development of gait disturbance and paralysis
sensory loss and numbness
Reflex changes:
- Increased below the level of lesion
- absent at the level of lesions

Question 11

State 5 causes of non-oncological causes of cord compression [5]

Answer 11

• Trauma
• Intervertebral disc prolapse
• Haematoma
• Epidural abscess (secondary to osteomyelitis or discitis)
• Cervical spondylitic myelopathy

Question 12

Malignant cord compression most commonly occurs in the [] spine

Cervical
Thoracic
Lumbar
Sacral.

Answer 12

Malignant cord compression most commonly occurs in the [] spine

Cervical
Thoracic
Lumbar
Sacral.

Question 13

Most cases of malignant cord compression (85-90%) occur secondary to metastatic extension from the [spinal anatomy]. This means pressure on the thecal sac tends occurs [direction].

Answer 13

Most cases of malignant cord compression (85-90%) occur secondary to metastatic extension from the vertebral bodies.

This means pressure on the thecal sac tends occurs anteriorly.

Question 14

An [] scan is the investigation of choice in suspected malignant cord compression.

How quickly does NICE rec. this to occur in? [1]

Answer 14

An MRI scan is the investigation of choice in suspected malignant cord compression.
- within 24 hours of presentation to the hospital

Sagittal T1 (fat appears bright) and T2 (fat and water appear bright) weighted images of the whole spine are required from an MRI scan, along with axial imaging

Question 15

Why might renal function be impaired in neoplastic spinal cord compression? [2]

Answer 15

due to underlying cancer such as in myeloma or prostate cancer if this is causing obstructive uropathy.

Question 16

How will neoplastic spinal cord compression differ from mechinical back pain? [1]

Answer 16

Differences - no associated neurological symptoms such as limb weakness or sphincter disturbance.

Question 17

Describe the managment plan for neoplastic spinal cord compression

Answer 17

Mobilisation:
- nursed supine and central spine alignment should be maintained.

Corticosteroids:
- immediate start on dexamethasone (reduces oedema helping to relieve compression) continued till a definitive treatment plan is made.

Analgesia

Sphincter function (bladder and bowel incontinence) needs to be assessed for daily
- Urinary catheterisation may be required for acute urinary retention.

Venous thromboembolism (VTE) prophylaxis due to cancer and immobility

Within 24 hours:
- Radiotherapy (external beam radiotherapy; stereotactic body radiotherapy) can be adjuvant or stand alone therapy
- surgical decompression and reconstruction, vertebroplasty and kyphoplasty

Question 18

Which scoring system is used to determine prognosis (and therefore suitability for surgical intervention)? [1]

Answer 18

revised Tokuhashi scoring system:
* Overall health
* The number of non-vertebral bone metastases
* The number of vertebral metastases
* The number of metastases to other internal organs
* Primary cancer
* Neurological deficit

Each parameter is scored 0-2

Question 19

State examples of osteoblastic [2] and osteolytic [4] bone mets.

Answer 19

Osteoblastic:
* prostate cancer
* hodgkin’s lymphoma
* small cell lung cancer

Osteolytic:
* renal cell cancer
* thyroid cancer
* melanoma
* non-small cell lung cancer
* non-Hodgkin’s lymphoma

Question 20

The most common primary cancers that lead to bone metastases are [5]

Answer 20

Breast
Bronchus
Thyroid
Prostate
Kidney

Question 21

Describe the clinical features of bone metastases [5]

Answer 21

Pain
- Classically wakes people from sleep AND described as gnawing pain like a toothache

Weight loss

Reduced mobility

Pathological fracture

Symptoms of hypercalcaemia
- when hypercalcaemia is found, 80% of patients are found to have metastases.

Question 22

Which investigational technique should be used to investigate for bone mets. [1]
Describe what results might indicate bone mets [2]

Answer 22

Bone scintigraphy
- increased uptake of the Technetium-99 or it is asymmetrical
- If the kidneys and bladder are not seen on the scan, this is a worrying sign and may be due to a severe bone disease or bone metastases which are taking up all of the Technetium-99 so none is needed to be excreted

Question 23

Describe the management plan for bone mets [5]

Answer 23

Oncology management will depend on the stage of the primary tumour and extent of metastases.

Treatment may include surgery to stabilise affected bones, radiotherapy, chemotherapy, or hormone therapy, but this will depend on the primary tumour and be decided by the specialists involved.

Analgesia
- NSAIDS; opoids

Immediate IV bisphosphonates.

Radiotherapy can be used palliatively on bone metastases to reduce pain and improve quality of life

Denosumab is a monoclonal antibody that helps to slow the progression of bone metastases. It works by inhibiting osteoclasts and therefore slowing the rate of bone turnover and bone loss.

Question 24

What is the bulbocavernosus reflex and why is it useful? [1]

Answer 24

squeezing the penis or the clitoris in a patient and monitoring the internal and external anal sphincter contraction in response
- useful test for checking whether the patient is in spinal shock after spinal trauma
- During the phase of shock, the bulbocavernosus reflex is absent and its return indicates the end of spinal shock.

Question 25

What is the Lazarevic’s sign? [1]

Answer 25

Lazarevic’s sign is the positive result of a straight leg raise, which indicates an underlying disc herniation, most likely at the L5 level.