Cortex - Adult orthopaedics spine and upper limb 2 (spine)

Question 1

What are the 4 main red flags regarding back pain that may indicate significant and serious underlying pathology is present,such as tumour, infection or spondylolisthesis ?

Answer 1

1. Back pain in the younger patient (<20 years)
2. New back pain in the older patient (>60 years)
3. Nature of pain ‐ constant, severe pain, worse at night (unlike mechanical back pain
4. Systemic upset - Fevers, night sweats, weight loss, fatigue and malaise may indicate the presence of underlying tumour or infection.

Question 2

What is the main difference between mechanical back pain and back pain from e.g. a tumour or infection ?

Answer 2

Mechanical back pain - is relieved by rest

Pain from tumour/infection - constant, unremitting, severe and worse at night.

Question 3

In terms of the back what can severe osteoporosis predispose patients to ?

Answer 3

Osteoporotic crush fractures

Question 4

What is the usual treatment of osteoporotic crush fractures ?

Answer 4

Treatment is usually conservative

Question 5

What is spondylosis?

Answer 5

It is a painful condition of the spine resulting from the degeneration of the intervertebral discs leading to increased load on the spine and accelerated OA.

Question 6

What may spondylosis cause if found lower in the spine (lumbar)

Answer 6

Can cause spinal stenosis

Question 7

If spondylosis is found higher up in the spine (cervical) what are some of the signs/symptoms it causes ?

Answer 7

Slow onset stiffness and pain in the neck which can radiate locally to shoulders and the occiput

Question 8

What is the treatment of spondylosis ?

Answer 8

Usually just physio and analgesics, but if conservative management doesn’t work and osteophytes formed cause compression resulting in radiculopathy it may require decompression

Question 9

Cervical disc prolapse is pretty much the same as lumbar disc prolapse (they can occur anywhere in the spine) - both can cause nerve root compression.

Answer 9

Appreciate this

Question 10

What are the nerve roots typically affected in cervical disc prolapse causing nerve root compression ?

Answer 10

Lower nerve roots - ie C7 root for C6/7 disc, C8 root for C7/T1 disc

Question 11

How would you diagnose the affected level by a disc prolapse ?

Answer 11

Clinical findings and MRI

Question 12

Many people are asymptomatic with disc prolapses so what would make you think that a disc prolapse is causing the signs/symptoms seen ?

Answer 12

If the clinical findings correlate with the MRI findings

Question 13

What is the treatment of disc prolapses ?

Answer 13

• 1st line - conservative
• 2nd line - discetomy

Question 14

In the spine what can RA cause ?

Answer 14

Atlanto‐axial subluxation - due to destruction of the synovial joint between the atlas and the dens and rupture of the transverse ligament.

(think about the joint as how things sit on an axis)

Question 15

What is the treatment of atlantoaxial subluxation (and cervical subluxations in general) ?

Answer 15

• Treatment is usually collar to prevent flexion
• More severe cases may require surgical fusion

Question 16

Note that cervical subluxations can occur lower as well - what is the worst case scenario from a cervical subluxation ?

Answer 16

Death due to spinal cord compression - with upper motor neuron signs (wide based gait, weakness, increased tone, upgoing plantar response)