Clinical conditions of cervical + thoracic vertebrae

Question 1

What is cervical spondylosis?

Answer 1

Chronic degenerative OA of intervertebral joints of C spine

Age-related disc degeneration, osteophytosis + facet joint OA

Question 2

What can cervical spondylosis lead to the narrowing of?

Answer 2

Intervertebral foramina = pressure on spinal nerves = RADICULOPATHY = paraesthesia, pain, motor weaknes

Spinal canal = pressure on spinal cord = MYELOPATHY = global muscle weakness, gait dysfunction, loss of bladder control

Question 3

What is a fracture of the atlas called?

Answer 3

Jefferson’s fracture = in ant. + post. arches of atlas

From axial loading = diving to shallow water, fall from playground equipment

Question 4

Why does a Jefferson fracture rarely cause neurological signs, only pain?

Answer 4

Bone fragments burst open = lower risk of spinal cord impingement
BUT artery damage @ base of skull = ataxia, stroke, Horner’s syndrome

Question 5

What is a fracture of the axis called?

Answer 5

Hangman’s fracture through pars interarticularis (between sup. + inf. articular processes)
Forcible hyperextension of head on neck (hanging or RTA)
Expand spinal canal = low risk of spinal cord injury

Question 6

What happens in a fracture of the odontoid process?

How is this fracture detected?

Answer 6

Osteoporotic elderly fall forwards + impact forehead on ground = hyperextension
Blow to back of head (against a wall when balance poor) = hyperflexion
Open mouth AP x-ray or CT of C spine

Question 7

What is whiplash injury and why is the C spine vulnerable to it?

Answer 7

Forceful hyperextension-hyperflexion injury of C spine

Has high mobility + low stability

Question 8

What is the typical mechanism for a whiplash injury?

Answer 8

Car struck from behind

1. @ impact, sudden acceleration forwards of vehicle = then by shoulders + trunk 100ms later
2. Head static as no force acting on it = forced extension of neck then head accelerates
3. Neck acts as lever to increase forward head acceleration, neck flexes
4. Tearing of C ligaments + muscles, oedema, haemorrhage, inflammation, muscle spasm = pain + stiff

Question 9

What are some symptoms of whiplash injury?

Answer 9

Lower back/arm/shoulder pain
Chronic myofascial pain syndrome
Spinal cord injury (not common as large vertebral foramen compared to width of spinal cord)

Question 10

What is a cervical intervertebral disc prolapse?

Answer 10

Cervical disc prolapse/herniation with compression of nerve roots/spinal cord (in 30-50yr olds)
Spontaneous in origin/trauma
Radiculopathy if spinal nerve impinged/spinal compression if canal-filling prolapse

Question 11

In a C5/6 prolapse, what will the patient complain of?

Answer 11

C nerves exit above vertebrae = exiting nerve root is C6

Paraesthesia in C6 dermatome, weakness in C6 myotome

Question 12

What is C spine myelopathy?

Answer 12

Spinal cord dysfunction from compression of the cord by narrowing of spinal canal
Can affect lower + upper limbs from damage to long tracts of spinal cord

Question 13

Causes of C spine myelopathy

Answer 13

Spinal canal stenosis from spondylosis (facet joint hypertrophy/disc protrusion/osteophytosis)

Disc herniation/spondylolisthesis/tumour/RA

Question 14

When the diameter of the spinal canal (17-18mm) falls below what diameter, will myelopathic symptoms be present?

Answer 14

12-14mm

Question 15

What are signs of C spine myelopathy?

Answer 15

Loss of balance, weakness, numbness, poss. paralysis
UPPER C LESIONS = loss of manual dexterity, disdiadochokinesia (impaired ability to perform rapid alternating movements)
LOWER C LESIONS = spasticity, loss of proprioception in legs, gait disturbance

Question 16

When the long tracts are damaged, patients have exaggerated response to stimulation, shown by what 2 signs?

Answer 16

HOFFMAN’S TEST = hold middle phalanx of middle finger + flick nail, normal if no movement in index finger/thumb

BABINKSI SIGN = stroke lateral side of sole of foot with blunt instrument from heel to toe, normal = plantarflex, abnormal = hallux dorsiflexes + toes fan out

Question 17

What is L’Hermitte’s phenomenon?

Answer 17

Sensation of intermittent electrical shocks in limbs, exacerbated by neck flexion (C spine myelopathy)

Question 18

If surgical decompression not performed in C spine myelopathy, what can occur?

Answer 18

Quadriplegia + sphincter dysfunction

Question 19

Myelopathy of C spine at C5 will cause what pain, motor weakness + sensory?

Answer 19

Neck pain
Weakness of shoulder abduction + lateral rotation (C%) AND weakness of all distal myotomes
Paraesthesia from shoulder distally (incl. lower limbs)

Question 20

What are causes of T spine cord compression?

Answer 20

Vertebral fractures + tumours in spinal canal
Spine = 2nd most common site for skeletal metastases (1st = pelvis)
Most common bone metastases arise from breast/lung/thyroid/kidney/prostate cancers

Question 21

By what 3 routes can pathogens reach the bones/tissues of the spine?

Answer 21

1 = haematogenous (septic via arterial supply/retrograde venous flow)
2 = direct inoculation in invasive spinal procedures (epidural)
3 = spread rom adjacent soft tissue infection (intervertebral disc is avascular so organisms deposit in vertebral body = ischaemia, infarct, necrosis to spread)

Question 22

What is infection of the intervertebral disc called an who does it commonly occur in?

Answer 22

Spondylodiscitis or discitis
Immunocompromised
Can get vertebral osteomyelitis

Question 23

By what mechanisms can spread of infection into the spinal canal lead to neurological damage?

Answer 23

Septic thrombosis = ischaemia
Compression of neural elements by epidural abscess
Invasion by inflammatory tissue
Mechanical collapse of bone = instability

Question 24

What organisms commonly infect the spine?

Answer 24

Staph. aureus, gram -ve bacilli, coagulase -ve Staph. (surgery)
IV drug users = candida