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Neuro Pathology > Diseases of the Spinal Cord and Nerve Roots > Flashcards

Diseases of the Spinal Cord and Nerve Roots Flashcards

1
Q

Presentation of UMN signs

A

No wasting
Increased tone
Increased reflexes
Pyramidal pattern of weakness

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2
Q

What is the pyramidal pattern of weakness in UMN lesion?

A

Flexors stronger than extensors

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3
Q

What does UMN stand for?

A

Upper motor neurone

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4
Q

What does LMN stand for?

A

Lower motor neurone

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5
Q

Presentation of LMN signs

A 
Decreased tone
Decreased reflexes
Plantar flexor 
Weakness
Muscle wasting
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6
Q

What does a hemicord sensory lesion lead to?

A

Brown-sequard syndrome

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7
Q

What does a radiculopathy lead to?

A

Dermatomal sensory loss

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8
Q

What are the types of sensory signs?

A

Myelopathy
Hemicord lesion
Radiculopathy

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9
Q

If there was a C5 cord lesion, what possible signs may be present?

A 
Wasting of C5 innervated muscles
Increased tone in LL > UL
Reflexes 
 - decreased in biceps
- increased all lower reflexes 
Sensory level
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10
Q

Extrinsic causes of myelopathy / radiculopathy

A 
Tumour 
Hemorrhage
AVM, dural fistula
Degenerative (spine)
Trauma
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11
Q

Causes of myelopathy

A 
Inflammation 
- Demyelination (MS)
- autoimmune (antibody mediated e.g. aquaporin 4, lupus)
- sarcoid
Vascular - ischaemic vs haemorrhage
Infective
- viral (HSV/HZV, 
- bacterial (TB, lyme, syphillis, brucella)
- schistosomiasis
Metabolic - B12 deficiency 
Malignant / infiltrative
Congenital / genetic
- friedrichs ataxia, spinocerebellar ataxias
Idiopathic
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12
Q

What is ischaemic myelopathy?

A

Spinal stroke/infarction

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13
Q

What foodstuffs is abundant in B12?

A

Meat
Fish
Animal by products
Legumes

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14
Q

Absorption of B12 from the gut requires what? Where is this produced from?

A 
Intrinsic factor (a binding protein)
Produced by gastric parietal cells
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15
Q

What is pernicious anaemia?

A

Autoimmune condition in which antibodies to intrinsic factor prevent vit B12 absorption

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16
Q

What is vit B12 deficiency a complication of?

A

Total gastrectomy
Crohn’s
Tape worms

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17
Q

What of the nervous system does Vit B12 affect?

A 
Myelopathy (L'hermittes)
Peripheral neuropathy 
Brain 
Eye/optic nerves
Brainstem 
Cerebellum
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18
Q

Presentation of B12 deficient myelopathy

A 
Paraesthesia hands and feet, areflexia
First UMN sign extensor plantars 
Degeneration of corticospinal tracts
- paraplegia
Degeneration of dorsal colums = sensory ataxia 
Painless retention of urine
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19
Q

Investigations of B12 deficient myelopathy

A

FBC
Blood film
B12

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20
Q

Treatment of B12 deficient myelopathy

A

Intramuscular B12 injection

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21
Q

Causes of spinal cord ischaemia

A 
Atheromatous disease (aortic aneurysm)
Thromboembolic disease (endocarditis, AF)
Arterial dissection (aortic)
Systemic hypotension 
Thrombotic haematological disease 
Hyper viscosity syndromes
Vasculitis
Venous occlusion 
Endovascular procedures
Decompression sickness
Meningovascular syphillis
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22
Q

Presentation spinal cord stroke

A

Ischaemic pain
- back / radicular
- visceral referred pain
- radiates around where intercostal nerves would be
Weakness
- usually paraperesis rather than quadraparesis
Numbness and paraesthesia
Urinary syndromes
- retention
- followed by bladder and bowel incontinence as spinal shock settles
Acute stages of UMN in spinal shock - floppiness

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23
Q

What risk factors may someone who presents with a spinal cord stroke have?

A

Vascular risk factors

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24
Q

What artery is usually affected in spinal cord stroke?

A

Anterior spinal artery

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25
Q

Occlusion of what artery can present as partial brown sequard syndrome?

A

Occlusion of central sulcal artery

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26
Q

Investigations of spinal cord stroke

A

MRI

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27
Q

Treatment of spinal cord stroke

A

OT and physio
Manageme vascular risk factors
Reduce risk of recurrence

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28
Q

How to reduce the risk of recurrence of spinal stroke?

A

Maintain adequate BP
Reverse hypovolaemia/arrythmia
Antiplatelet therapy

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29
Q

What does the return of function depend on in spinal cord stroke?

A

The degree of parenchymal damage

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30
Q

What is a good prognostic indicator of recovery in spinal cord stroke?

A

Significant motor recovery within 24 hours

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31
Q

Mortality of spinal cord stroke

A

20%

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32
Q

What is demyelinating myeltiis a common cause of?

A

Medical spinal cord disease

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33
Q

What is MS characterised by?

A

Pathological lesions of inflammation and demyelination leading to temporary neuronal dysfunction

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34
Q

What does MS affect?

A

White matter of the CNS

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35
Q

Treatment of MS

A

Supportive

Methylprednisolone

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36
Q

What are the vertebral ligaments?

A 
Anterior longitudinal 
Posterior longitudinal 
Ligamentum flavum 
Interspinal ligament
Supraspinous ligament
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37
Q

Where does the spinal cord extend from and to?

A

C1 - L2

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38
Q

What dermatome is C6?

A

Thumb

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39
Q

What dermatome is C7?

A

Middle finger

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40
Q

What dermatome is C8?

A

Pinky

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41
Q

C5 myotome

A

Elbow flexors

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42
Q

C6 myotome

A

Wrist extensor

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43
Q

C7 myotome

A

Elbow extensors

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44
Q

C8 myotome

A

Finger extensors

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45
Q

T1 myotome

A

Intrinsic hand muscles

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46
Q

L2 myotome

A

Hip flexors

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47
Q

L3 myotome

A

Knee extensors

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48
Q

L4 myotome

A

Ankle dorsiflexors

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49
Q

L5 myotome

A

Long toe extensors

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50
Q

S1 myotome

A

Ankle plantar flexors

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51
Q

Signs of UMN lesion

A 
Weakness PRESENT 
Atrophy ABSENT
Reflexes INCREASED 
Tone INCREASED
Fasiculations ABSENT 
Babinski PRESENT
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52
Q

Signs of LMN Lesions

A 
Weakness PRESENT 
Atrophy PRESENT
Reflexes DECREASED 
Tone DECREASED 
Fasiculations PRESENT 
Babinski ABSENT
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53
Q

What is classed as an UMN and LMN lesion?

A

UMN - anterior horn of the spinal cord or above

LMN - distal to this

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54
Q

What would a C6 spinal cord lesion present with?

A

Weakness in elbow below sensory level at C6 and in legs
Reduced sensations after C6 - starts to have weakness in their hands
Power in shoulders but probably not below that
Increased tone in legs
Brisk reflexes
Babinski +ve
UMN!!

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55
Q

Definition of myelopathy. Is it an UMN or LMN lesion?

A

Neurological deficit due to compression of the spinal cord

UMN

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56
Q

What would a L4 nerve root lesion present with?

A 
Pain down ipsilateral leg
Numbness in T4 dermatome 
Weakness in ankle dorsiflexion = myotomes 2,3,4
Reduced knee jerk 
LMN!!
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57
Q

Definition of radiculopathy. Is it an UMN or LMN lesion?

A

Compression of the nerve root leading to dermatomal and myotomal deficits
LMN

58
Q

Definition of disc prolapse

A

Acute herniation of intervertebral disc causing compression of spinal roots or spinal cord

59
Q

Presentation of disc prolapse

A

Acute onset pain
- leg / arm
Sciatica
Numbness and weakness in the distribution of the nerve root involved

60
Q

Investigation of disc prolapse

A

MRI

61
Q

Definition of sciatica

A

Shooting pain down the leg into the ankle

62
Q

What will a disc prolapse in the cervical spine cause?

A

Myelopathy (UMN lesion)

63
Q

What will a disc prolapse in the lumbar region cause?

A

UMN of L1 and LMN below it

64
Q

Treatment of disc prolapse

A

Rehab
Nerve root injection
- steriods and anaesthetics
Lumbar/cervical disectomy

65
Q

What is a discectomy?

A

Remove the disc

66
Q

Nerve root injections give pain relief for approx. how long?

A

2 weeks

67
Q

Types of spinal tumours

A

Extradural (55%)
Intradural (40%)
Intramedullary (5%)

68
Q

Types of intramedullary spinal tumours

A

Astrocytome
Ependymoma
Teratoma
Hemangioblastoma

69
Q

Types of intradural spinal tumours

A

Meningioma
Neurofibroma
Lipoma

70
Q

Types of extradural spinal tumours

A 
Mets
- lung
- breast
- prostate
Primary bone tumours
- chondromas
- oesteoblastomas
- osteiud osteoma
71
Q

Presentation of malignant cord compression

A

Pain
Weakness
Sphincter disturbance

72
Q

Treatment of malignant cord compression

A

Surgical decompression
Radiotherapy
Cancer treatment

73
Q

Examples of spinal infections

A

Osteomyelitis
Discitis
Epidural abscess

74
Q

Where would you get osteomyeltiis of the spine?

A

Within the vertebral body

75
Q

Where would you get discitis of the spine?

A

Intervertebral disc

76
Q

Where would you get an epidural abscess?

A

Epidural space

77
Q

Presentation of epidural abscess

A

Back pain
Pyrexia
Focal neurology

78
Q

Investigations of epidural abscess

A

Urgent MRI

79
Q

Treatment of epidural abscess

A

Urgent surgical decompression

Long term IV antibiotics

80
Q

Causative organisms of epidural abscess

A

Staph aureus
Streptococcus
E coli

81
Q

Risk factors for epidural abscess

A

IV drug abuse
DM
Chronic renal failure
Alcoholism

82
Q

Risk factors for osteomyelitis of the spine

A 
IV drug abuse
DM
Chronic renal failure
Alcoholism 
AIDs
83
Q

Treatment of osteomyleitis of the spine

A

Antibiotics

Surgery if evidence of neurology

84
Q

Who is the loss of normal spinal structure seen in?

A

Older patients

85
Q

Pathology of normal loss of spinal structure in elderly

A 
Product of
- disc prolapse
- ligamentum hypertrophy 
- oestophyte formation 
Leading to 
- myelopathy 
- radiculopathy
86
Q

Definition of cervical spondylosis

A

Umbrella term for degenerative change in cervical spine leading to spine and nerve root compression

87
Q

Presentation of cervical spondylosis

A

Myelopathy

Radiculopathy

88
Q

Speed of onset of cervical spondylosis

A

Months to years

89
Q

Treatment of cervical spondylosis

A

Conservative if no / mild myelopathy

Surgery for progressive / severe

90
Q

Presentation of lumbar spinal stenosis

A

Pain down both legs ‘spinal claudication’

Worse on walking/standing and relieved by sitting/bending forward

91
Q

Treatment of lumbar spinal stenosis

A

Lumbar laminectomy

92
Q

Is lumbar spinal stenosis an emergency?

A

No

93
Q

What is similar to lumbar spinal stenosis that is an emergency?

A

Cauda equina syndrome

94
Q

What is cauda equina syndrome?

A

Large disc prolapse in combination with clinical signs

All nerve roots are compressed

95
Q

What is the triad of cauda equina syndrome?

A

Bilateral sciatica
Saddle anaesthesia
Urinary dysfunction

96
Q

Investigations of cauda equina syndrome

A

Urgent MRI

97
Q

Treatment of cauda equina syndrome

A

Emergency lumbar dissectomy

98
Q

What does brown sequard syndrome result in?

A

LOSS of proprioception and PARALYSIS on the SAME side as the lesion
LOSS of pain and temp on the OPPOSITE SIDE of the lesion

99
Q

What signs does MND result in? What does it affect?

A

A combination of UMN and LMN signs

Affects both upper (corticospinal) tracts and lower tracts

100
Q

What signs does poliomyelitis result in? What does it affect?

A

Affects ANTERIOR HORN CELLS resulting in LMN signs

101
Q

What tracts does brown sequard syndrome affect?

A
  1. Lateral corticospinal tracts
  2. Dorsal columns
  3. Lateral spinothalamic tracts
102
Q

What causes subacute combined degeneration of the spinal cord?

A

Vitamin B12 and E deficiency

103
Q

What tracts does the subacute combined degeneration of the spinal cord affect?

A
  1. Lateral corticospinal tracts
  2. Dorsal columns
  3. Spinocellebellar tracts
104
Q

What does subacute combined degeneration of the spine result in?

A

Bilateral spastic paralysis
Bilateral loss of proprioception and vibration sensation
Bilateral limb ataxia

105
Q

What does friedrichs ataxia result in?

A
  1. Lateral corticospinal tracts
  2. Dorsal columns
  3. Spinocerebellar tracts
106
Q

Presentation of friedrichs ataxia

A

Bilateral spastic paralysis
Bilateral loss of proprioception and vibration sensation
Bilateral limb ataxia
Cerebellar ataxia e.g. intention tremor

107
Q

What tracts are affected in anterior spinal artery occlusion?

A

Lateral corticospinal tracts

Lateral spinothalamic tracts

108
Q

Presentation of anterior spinal artery occlusion

A

Bilateral spastic paresis

Bilateral loss of pain and temp sensation

109
Q

Tracts affected in synringomyelia

A

Ventral horns

Lateral spinothalamic tract

110
Q

Presentation of synringomyelia

A 
Flaccid paralysis (typically affecting intrinsic hand muscles)
Loss of pain and temp sensation
111
Q

What tracts are affected in MS?

A

Asymmetrical, varying spinal tracts involved

112
Q

What tract is involved in neurosyphilis?

A

Dorsal columns

113
Q

Presentation of neurosyphillis

A

Loss of proprioception and vibration sense

114
Q

Risk factors for degenerative cervical myelopathy

A

Smoking (due to effects on intervertebral discs)
Genetics
Occupation (high axial loading)

115
Q

Symptoms of degenerative cervical myelopathy

A 
VERY VARIABLE
Pain (neck, upper and lower limbs)
Loss of motor function 
Loss of sensory function - numbness
Loss of autonomic function (incontinence, impotence)
Symptoms of carpal tunnel syndrome 
Hoffmans sign
116
Q

What does hoffmans sign investigate for and explain it?

A

Degenerative cervical myelopathy
Gently flick one finger on a patients hand - +ve test is when twitching of the other fingers on the same hand in response to the flick

117
Q

Investigation of degenerative cervical myelopathy

A

MRI spine - gold standard

118
Q

Management of degenerative cervical myelopathy

A

Urgent referral to assessment by special spinal services

Decompressive surgery

119
Q

What in degenerative cervical myelopathy confers best prognosis?

A

Early surgery within 6 months of diagnosis

120
Q

If neuropathic pain originally doesn’t resolve with conventional treatment, what opoid can be tried?

A

Tramadol

121
Q

What is the only nerve root that originates below a vertebrae? How does this differ from other nerve root names?

A

C8

The rest of the cervical spine roots derive their name from the vertebrae below them

122
Q

Nerve root of ankle reflex

A

S1 - S2

123
Q

Nerve root of knee reflex

A

L3 - L4

124
Q

Nerve root of biceps reflex

A

C5 - C6

125
Q

Nerve root of triceps reflex

A

C7 - C8

126
Q

What does a high stepping gait compensate for?

A

Foot drop

127
Q

What is bilateral foot drop meant to be due to?

A

Peripheral neuropathy

128
Q

What is unilateral foot drop due to?

A

Common peroneal nerve lesion

129
Q

What does the lesion of the common peroneal nerve lead to?

A

Weakness of dorsiflexion

Weakness of foot eversion

130
Q

What indicates autonomic dysreflexia and when does this occur?

A 
Occurs if the spinal cord injury is above the C6 level 
Combination of
- severe HTN
- flushing
- sweating
- no congruent response in HR
131
Q

Triggers of autonomic dysreflexia

A

Things that cause a sympathetic spinal reflex via thoracolumbar outflow e.g.
- faecal impaction
- urinary retention
Others

132
Q

Management of autonomic dysreflexia

A

Removal / control of stimulus

Tx life threatening HTN or bradycardia

133
Q

What is subacute degeneration of the spinal cord often due to?

A

Vitamin B12 deficiency

134
Q

What could be a warning sign for degenerative cervical myelopathy?

A

Progressive condition, worsening, deteroriation or new symptoms

135
Q

What is thoracic outlet syndrome?

A

A disorder involving compression of the brachial plexus, subclavian artery or vein at the site of the thoracic outlet

136
Q

Types of thoracic outlet syndrome

A

Can be

  • neurogenic OR
  • vascular
137
Q

Pathology of TOS (thoracic outlet syndrome)

A

When neck trauma occurs in individuals with anatomical predispositions - either an acute incidence or repeated stress
Anatomical anomalies can be either
- soft tissue (70%) or
- osseous structures (30%)

138
Q

Example of a well known osseous structure predisposing to TOS

A

Presence of a cervical rib

139
Q

Examples of soft tissue anomalies predisposing to TOS

A

Scalene muscle hypertrophy

Anomalous bands

140
Q

What is there usually a history of preceding TOS?

A

Neck trauma

141
Q

Presentation of neurogenic TOS

A

Painless muscle wasting of the hands with patients complaining of hand weakness e.g. grasping
Sensory symptoms such as numbness and tingling
If autonomic nerves are involved
- cold hands
- blanching
- swelling

142
Q

Presentation of vascular TOS

A

Subclavian vein compression leads to painful diffuse arm swelling with distended veins
Subclavian artery compression leads to painful arm claudication and in severe cases ulceration and gangrene

Neuro Pathology (21 decks)

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