Conditions Of The Spine And Surgery Flashcards
What could cause back pain?
- cauda equina
- spinal fracture
- malignancy
- discitis
- TB of spine (Pott’s disease)
- pylonephritis
- referred pain
Define radiculopathy
- a conduction block in the axons of a spina nerve or its root
- this impacts on motor axons > motor weakness
- this impacts spinal axons > Paraesthesia
Define radicular pain
A pain deriving from damage or irritation of spinal nerve tissue (particularly dorsal root ganglion)
Causes of radiculopathy
nerve compression which can be caused by:
- intervertebral disc prolapse
- degenerative diseases of the spine
- fracture
- malignancy
- infection e.g. osteomyelitis, TB/Pott’s disease, herpes zoster
What is Pott’s disease?
Tuberculosis of the spine
Presentation of radiculopathy
- parathesia + numbness
- weakness
- radicular pain
- ask about red flags
Management of radiculopathy
- depends on underlying cause
- cauda equina syndrome is the only condition requiring emergency surgical treatment
- analgesia: amitriptyline first line
- Physiotherapy
Analgesia for radiculopathy
amitriptyline first line
pregabalin
gabapentin
Define lumbago
Lower back pain
Causes of mechanical back pain
- muscle or ligament sprain
- facet joint dysfunction
- sacroiliac joint dysfunction
- herniated disc
- spondylolisthesis
- scoliosis
- arthritis
What is spondylolithesis?
Anterior displacement of vertebra out of line with the one below it
Causes of neck pain
- muscle or ligament sprai
- torticollis
- headache
- whiplash
- cervical spondylosis
Red flags that could indicate ankylosing spondylitis
- <40
- gradual onset
- morning stiffness > 30 mins
- night time pain
Red flags suggestive of spinal infection
Fever
IV drug user
Red flags for back pain
- thoracic pain
- <20 or >55
- non-mechanical pain
- pain worse when supine
- night pain
- weight loss
- associated with systemic illness
- neurological signs
- cauda equina red flags
- IV drug use
- immunosuppression or steroid use
- cancer or HIV
- structural deformity
Nerve roots of the sciatic nerve
L4-S3
What does the sciatic nerve split into?
Where?
Tibial nerve
Common peroneal nerve
At the popliteal fossa
Presentation of sciatica
- Unilateral pain from buttock radiating down back of thigh to the knee or foot
- electric shock/shooting pain
- Paraesthesia
- numbness
- motor weakness
Causes of sciatica
- herniated disc
- spondylolithesis
- spinal stenosis
What test is used to help diagnose sciatica?
Sciatic stretch test
Outline the sciatic stretch test
- patient lies on back with leg straight
- examiner lifts one leg from the ankle with knee extended until hip flexion is reached
- examiner dorsiflexes the ankle
- sciatica type pain in buttock/posterior thigh indicates sciatic nerve root irritation
What are the main cancers that metastasise to the bone?
- prostate
- breast
- lung
- thyroid
- renal
Investigations of back pain
- X-ray or CT scan for fractures
- emergency MRI scan in suspected cauda equina
- X ray, MRI + inflammatory markers for ankylosing spondylitis
Management of sciatica
- amitryptyline or duloxetine first line
- do not use oral corticosteroids, opioids or gabapentin or pregabalin
- epidural corticosteroid injection
- local anaesthetic injections
- radiofrequency denervation
- spinal decompression
What is the STarT Back screening tool used for?
- To stratify the risk of a patient presenting with acute back pain developing chronic back pain
- helps to guide the intensity of initial investigations
Outline the STarT Back screening tool
- Used to stratify the risk of a patient with acute back pain developing chronic back pain
- 9 questions assessing function + psychological response to back pain
Management of acute lower back pain
- exclude serious underlying causes
- STarT Back tool to stratify risk of developing chronic back pain
- low risk: analgesia, reassurance, stay active, eduction
- moderate or high risk: physio, group exercise, CBT
- analgesia for low back pain: NSAIDs first line, codeine, benzodiazepines short term for muscle spams
- avoid opioids, antidepressants, amitriptyline, gabapentin or pregabalin
What is first line analgesia for low back pain
NSAIDs
What should you do if ankylosing spondylitis is suspected?
- inflammatory markers CRP ESR
- HLA-B27 gene testing
- X-ray spine + sacrum
- MRI spine
- urgent rheumatology review
Imaging results of ankylosing spondylitis -
MRI: bone marrow oedema
X ray:
- bamboo spine
- squaring of vertebral bodies
- subchondral sclerosis + erosions
- sydesmophytes
- ossification of ligaments, discs + joints
Management of ankylosing spondylitis
- NSAIDs first line
- anti TNF meds second line
- mab against IL-17 third line
- intra-articular injections
- Physiotherapy
- exercise + mobilisation
- avoid smoking
What is cauda equina syndrome?
A surgical emergency where the nerve roots of cauda equina are compressed
L3 L4 L5 S1 S2 S3 S4 S5 Co
What is the sensory, motor + parasympathetic innervation of cauda equina?
- sensory: lower limbs, perineum, bladder, rectum
- motor: lower limbs, anal+ urethral sphincters
- parasympathetic: bladder + rectum
Causes of cauda equina
- herniated disc
- tumours
- spondylolisthesis
- abscess
- trauma (vertebral fracture + subluxation)
Red flags of cauda equina
- saddle anaesthesia
- loss of sensation in balder + rectum
- urinary retention or incontience
- faecal incontience
- bilateral sciatica
- bilateral motor weakness in legs
- reduced anal tone on PR exam
Management of cauda equina
- immediate Hosptial admission
- emergency MRI scan of lumbar-sacral
spine - PR exam
- bladder scan
- neurosurgical review for urgent lumbar decompression surgery
What is a late sign of cauda equina + therefore associated with poor outcome?
urinary incontinence
What is metastatic spinal cord compression?
Compression of the spinal cord due to a metastatic lesion
Oncological emergency
Key feature of metastatic spinal cord compression
Back pain that is worse on coughing or straining
Management of metastatic spinal cord compression
- high dose dexamethasone
- analgesia
- surgery
- radiotherapy
- chemotherapy
Compare the presentation of cauda equina + metastatic spinal cord compression
- cauda equina: lower motor neurone signs - reduced tone + reflexes
- MSCC: upper motor neurone signs - increased tone, brisk reflexes,
Lower motor lesion signs
- weakness
- hyporeflexia or areflexia
- hypotonia
- muscle atrophy
- fasciculations
Upper motor lesion signs
- weakness
- hypertonic
- Hyperreflexia
- clasp knife rigidity
- atrophy
Causes of acute spinal cord compression
- metastatic spinal cord compression
- trauma (vertebral fracture or subluxation)
- abscesses
- disc prolapse
Risk factors for spinal cord compression
- thyroid, renal, breast, lung, prostate cancer
.
Any pathology that can predispose to a narrowed cord canal - RA
- ankylosing spondylitis
- ligamentum flavum hypertrophy
- osteophytes
Clinical features of spinal cord compression
- sensation + proprioception impaired below cord compression
- pain worse on coughing or sneezing
- weakness
- upper motor neurone signs e.g. hypertonia, hyperreflexia
What is gold standard for suspected spinal cord compression?
MRI of whole spine
Management of spinal cord compression
- high dose corticosteroids |dexamethoasone
- immediate referral to neurosurgery
- definitive treatment: spinal cord decompression
- radio/chemotherapy
What is spinal stenosis?
What is the most common location?
Narrowing of a part of the spinal cord
Resulting in compression of the spinal cord or nerve roots
Lumbar spine
Three types of spinal stenosis
- central stenosis: narrowing of central spinal canal
- lateral stenosis: narrowing of the nerve root canals
- foramina stenosis: narrowing of the intervertebral foramina
Causes of spinal canal stenosis
- congenital spinal stenosis
- herniated discs
- thickening of ligamentum flavum
- spinal fractures
- tumours
- spondylolithesis
- degenerative changes
Presentation fo spinal stenosis
intermittent neurogenic claudications (central stenosis)
- lower back pain
- buttock + leg pain
- leg weakness
- absent at rest
- occur when standing or walking
- bending forwards improves symptoms
.
- sciatica in lateral or foramina stenosis
Investigations for spinal stenosis
- MRI of spine
- exclude peripheral arterial disease: ankle-brachial pressure index + CT angiogram
Management of spinal stenosis
- exercise + weight loss if appropriate
- analgesia
- Physiotherapy
- decompression surgery
- laminectomy
What area of the spinal is most commonly infected?
Lumbar spine
Then thoracic
Types of spinal infections
- vertebral osteomyelitis/spondylitis
- discitis
- epidural abscess
- sub dural abscess
- spinal cord abscess
What are the three main routes pathogens can cause a spinal infection
- Haematogenous (most common)
- direct inoculation
- adjacent spread
What are the most common organisms causing spinal infections?
Staphylococcus aureus
E. coli
Risk factors of spinal infection
IV drug use
Immunosuppression
Malignancy
Diabetes mellitus
Recent spinal surgery
Presentation of spinal infection
- back pain
- worse on movement + at night
- pyrexia
- tender on spine examination at level of infection
- neurological compromise
Investigations of suspected spinal infection
- routine bloods
- blood cultures
- MRI spine with contrast
- CT to determine extent of bony involvement
- CT guided biopsy > microbiology + histology
What is the imaging of choice for osteomyelitis?
MRI
Management of spinal infections
- Long term IV abx/antifungals
- immobilisation
- surgery is indicated if there is significant bone destruction, presence of neurological deficits or poor response to abx
- debridement + drainage
When is surgery indicated in spinal infections?
- significant bone destruction
- presence of neurological deficits
- poor response to abx
What classification is used to describe cervical spine fractures?
AO classification
What is a Jefferson fracture?
What is it caused by?
- Burst fracture of the atlas C1
- caused by axial loading of cervical spine
What is a hangman’s fracture?
What is it caused by?
- fracture through the pars interarticularis of C2 bilaterally
- often with subluxation of C2 on C3
- caused by cervical hyperextension + distraction
What is cervical spondylosis?
Osteoarthritis of IV joints
Triad of presentation of cervical spondylosis
- loss of disc height
- osteophytes
- facet joint space OA
Mechanisms of odontoid process fracture
- hyperflexion: blow to back of head
- hyperextension: falling + impact to forehead
Investigation of suspected cervical fracture
- CT in adults
- MRI in children
- X-ray in children who do not fit criteria for MRI
- MRI to look at soft tissue injury
Management of cervical fracture
- 3 point C spine immobilisation
- restricting movement fo spine
- stable fracture: rigid collars or halo vests
- traction devices - definitive treatment of stable
- unstable fractures: stabilisation: fusion of damaged vertebra to the one above + below
What is the most commonly fracture region of the spine?
Thoracolumbar junction
T11-L2
Classification of thoracolumbar fractures
AO classification
- type A: compression injuries
- type B: distraction injuries
- type C: translation injuries
Outline a burst fracture
occurs when there is substantial compressive force acting through the anterior + middle column of the ventral > retropulsion of the bone into the spinal canal
Outline a chance fracture
vertebral fractures that result from excessive flexion of the spine
e.g. head on RTC
Investigations of thoracolumbar fracture
- X ray first line if no abnormal neurological presentation
- CT if there is suspicion of spinal column injury
- MRI to look at soft tissue injury
Management of thoraclumbar fracture
- restrict movement of spine
- stable fracture: extension bracing or lumbar corsets
- analgesia
- Physiotherapy
- unstable fractures: decompression + spinal fusion
What is degerative disc disease?
Natural deterioration of the IV disc structure > progressive weakness + collapse
Pathophysiology of degernative disc disease
- dysfunction: outer annular tears + separation of endplate, cartilage destruction + facet synovial reaction
- instability: disc resportion + loss of disc height > subluxation + spondylolisthesis
- re stabilisation: osteophyte formation + canal stenosis
Clinical features of degenerative disc disease
- local spinal tenderness
- contracted paraspinal muscles
- hypo mobility
- painful extension of back or neck
When is imaging indicated in suspected degenerative disc disease?
- red flags present
- radiculopathy with pain > 6 weeks
- evidence of spinal cord compression
What imaging is gold standard in suspected degenerative disc disease?
MRI spine
Management of degenerative disc disease
- analgesia
- encourage mobility
- Physiotherapy
- referral to pain clinic if pain persists > 3 months
What is needed in rib fractures to reduce risk of chest infection?
adequate analgesia
so patient can fully expand chest
If normal analgesia is not adequate for rib fracture pain management, what is next line?
regional nerve block
What is flail chest?
Life threathening chest injury where 2+ ribs break + become detached from chest wall
what is flail chest characterised by?
paradoxical movement of flail segment when breathing
Management of flail chest
immediate surgical management + invasive ventilation
Investigations of rib fracture
- CT scan best diagnostic tool
- chest X ray
Management of rib fracture
- most conservatively
- adequate analgesia
- regional nerve block next line
- surgical fixation if flail lung or failure to head after 12 weeks conservative Tx
features of a prolapsed disc
- dermatomal leg pain with associated neurological deficits
- leg pain worse than back pain
- pain worsen when sitting
Features of L3 nerve root compression
- sensory loss over anterior thigh
- weak hip flexion, knee extension + hip ADduction
- reduced knee reflex
- positive femoral stretch test
features of L4 nerve root compression
- sensory loss anterior knee + medial malleolus
- weak knee extension + hip ADduction
- reduced knee reflex
- positive femoral stretch test
features of L5 nerve root compression
- sensory loss to dosrum of foot
- weakness in foot + big toe dorsiflexion
- reflexes intact
- positive sciatic nerve stretch test
features of S1 nerve root compression
- sensory loss to posterolateral aspect on leg + lateral aspect of foot
- weakness in plantar flexion of foot
- reduced ankle reflex
- positive sciatic nerve stretch test
Management of prolapsed disc
- NSAIDs
- physiotherapy
- if persists 4-6 weeks, consider referral for MRI
