Lecture 12 Clinical Correlates Flashcards
What is cervical spondylosis?
Chronic degenerative osetoarthritis affecting intervertebral joints in the cervical spine
(disc degeneration, narrowing of joint space, osteophytes)
What is the primary pathology in cervical spondylosis?
- Age-related disc degeneration
- osteophytosis (osteophytes formation adjacent to end plates of vertebral bodies)
- facet joint osteoarthitis
How can cervical spondylosis cause radiculopathy/myelopathy?
- narrowing of intervertebral foramina can put pressure on spinal nerves= RADICULOPATHY
- narrowing of spinal canal can put pressing on the spinal cord= MYELOPATHY (less common)
Symptoms of myelopathy/radiculopathy:
Myelopathy: global muscle weakness, gait dysfunction, loss of balance, loss of bowel/bladder control
Radiculopathy: dermatomal sensory symptoms (pain/paraesthesia), myotomal motor weakness
What is Jefferson’s fracture?
Fracture of anterior/posterior arches of atlas vertbra
- due to axial loading (down centre)
- present to A&E supporting head in their hands
- bursting open of C1
What damage does the Jefferson’s fracture cause?
- pain but NO neurological signs (burst reduces impingment on spinal cord)
- may be damage to arteries at base of skull leading to secondary sequelae (stroke, ataxia, Horner’s syndrome)
What does ‘sequelae’ mean?
Condition resulting from another disease
What is ataxia?
Group of disorders affecting balance, speechand co-ordination
What is Horner’s syndrome?
Damage to symathetic trunk
- miosis (decreased pupil size)
- partial ptosis (droopy eyelid)
- anhidrosis (reduced sweating on affected side of face)
- enophthalmos (sunken appearance of eyes)
What is Hangman’s fracture?
Axis vertebra is fractured through pars interarticularis
- due to forcible hyperextension
- fracture is unstable and requires treatment
Does Hangman’s fracture cause injury?
Fracture tends to expand spinal canal, reducing risk of spinal cord injury
What is an odontoid process fracture caused by?
Flexion/extension
Hyperextension injury of cervical spine: elderly with osteoporosis falling forward onto forehead
Hyperflexion: falling against a wall
How do you detect and odontoid fracture?
- open mouth AP X-ray
- CT of cervical spine
What is whiplash?
Forceful hyperextension-hyperflexion injury of the cervical spine causing tearing of cervical muscles/ligaments
e.g. a car being struck from the rear
Why is the cervical spine prone to whiplash?
The head is 7-10% of body weight and is balanced on cervical spine which has high mobility/low stability
What does hyperextension/hyperflexion lead to?
Secondary oedema
Haemorrhage
Inflammation
Muscles respond by contracting in attempt to splint neck= neck stiffness and pain
What are the symptoms of whiplash?
Arm pain/paraesthesia
- shoulder injuries due to holding steering wheel at time of collision
- lower back pain
What can develop in response to disc/facet joint injury?
Chronic myofascial pain syndrome
What is a protective measure against spinal chord injury in the cervical spine?
Large vertebral foramen
Can whiplash result in spinal cord injury?
Yes to the cervical cord
- significant movement of vertbrae as it is highly mobile and ligaments/capsules are loose
- soft tissue swelling is seen (there is no fracture)
How does cervical intervertebral disc prolapse occur?
- tear in annulus fibrosus
- nucleus pulposus protrudes with impingement into adjacent nerve root/spinal cord
- sometimes sequestration occurs where some of the extruded nucleus pulposus separates and enters the spinal canal where it is eventually resorbed resolving symptoms
What age group does cervical intervertebral disc prolapse occur in?
30-50 yo
Why does only a small herniation cuase significant pain in cervical region?
Discs arent very large, so little space available for exiting nerves so a small herniation can impinge on a nerve and cause pain
What symptoms occur in cervical intervertebral disc herniation?
Depends on site of prolapse
Paracentral: impinge of spinal nerve > radiculopathy
Canal filling prolapse: acute spinal cord compression
What will a patient with a left sided C5/6 prolapse complain of?
Paraesthesia in left C6 dermatome
Weakness in left C6 myotome
Pain in neck that will radiate down left arm to C6
What is cervical myelopathy?
Spinal cord dysfunction due to compression of the cord by narrowing of the spinal canal
What is a common cause of cervical myelopathy and who does it affect?
Degenerative stenosis of spinal canal due to cervical spondylosis
50-80 yos
What is cervical spondylotic myelopathy?
Myelopathy secondary to cervical spondylosis
-result of degenerative changes in age
What are some degenerative changes that develop with age leading to cord compression?
-ligamentum flavum hypertrophy/buckling
-facet joint hypertrophy
-disc protrusion
-osteophyte formation
Reduce diameter in spinal canal
What are some causes leading to cervical myeolopathy?
- congenital stenosis of spinal canal
- cervical disc herniation
- spondylolisthesis (anterior slippage of vertebral body on one below)
- trauma
- tumour
- RA affecting cervical spine
What is the normal width of the spinal canal and the width where you myelopathic experience?
17-18 mm
Myelopathic symptoms: 12-14 mm
What are the symptoms of cervical myelopathy?
Non-specific
- may manifest also in lower/upper limb symptoms due to damage of long tracts of the spinal cord
- loss of balance
- poor coordination
- decreased dexterity
- weakness
- numbness
- paralysis in severe cases
- rapid deterioration of gait and hand function (ofetn in older patients)
Is pain a symptom of cervical myelopathy?
Not always
-absence of pain often leads to delay in diagnosis
What do upper cervical lesions often cause?
- loss of manual dexterity
- dysdiadochokinesia: impaired ability to perform rapid alternating movements
What do lower cervical lesions lead to?
Spasticity and loss of proprioception in legs
- legs feel heavy and experience reduced exercise tolerance
- gait disturbance: many falls
What happens when a long tract in the spine becomes damaged?
Protective capabilities are less effective. Long tracts usually dampen spinal reflexes so a person does not overreact to stimuli
- so patient may demonstrate an exagerrated reponse to stimulation
- seen in positive HOFFMAN’s/BABINSKI sign
What is teh Hoffman’s test?
Dr holds middle finger at middle phalanx and flicks fingernail
- if patients thumb/index finger don’t move= normal/negative
- if patients thumb/index finger move= abnormal/positive
What is the Babinski sign?
Lateral side of foot is stroked from heel to toes
- people over 2/3 years: toes flex downwards (plantarflex)
- Abnormal/positive: hallux (big toe) dorsiflexes, toes fan
What is L’Hermitte’s phenomenon?
Sensationof intermittent electric shocks in limbs, exacerbated by neck flexion (associated with cervical myelopathy)
What happens when compresssion to spinal cord is severe?
- quadriplegia (paralysis of all 4 limbs)
- sphincter dysfunction (obstruction in bile flow: can lead to pancreatitis)
What happens if a patient develops myelopathy at level of C5?
- neck pain
- weakness of shoulder abduction, external rotation, weaknessof all myotomes distally
- paraesthesia from shoulder distally, trunk and lower limbs
What are the most common causes of thoracic cord compression?
- vertebral fractures with bony fragments in spinal canal
- tumours in spinal canal (metastases to spine are very common- especially from lung, thyroid, kindey, prostate, breast)
What would a metastasis in T12 cause and why?
Compresion of L4-L5 segments of spinal cord
-as the cord is shorter than the vertebral column
How do pathogens reach bones/tissues of the spine?
- haematogenous
- direct inoculation during invasive spinal procedures
- spread from adjacent soft tissue infection
What is the most common route for a septic focus from somewhere else in the body to reach the spine?
Haematogenous spread via arterial blood supply to vertebral bodies but can occur through venous retrograde
What is infection of the vertebral disc called?
Spondylodiscitis/discitis
-commonly occurs in immunocomprimsied patients (diabetes/HIV)
How do organisms enter the disc?
In adults the disc is avascular, so organisms are deposited in vertebral body by segmental artery leading to bony ischameia and infarction.
-necrosis of bone allows direct spread of organisms to adjacent disc space, epidural space, adjacent vertebral bodies
Most common organisms in spinal canal infection:
- staphylococcus aureus
- gram negative bacilli (E.coli)
Most common organisms to infect after a surgical procedure:
-coagulase-negative staphylococci (staph.epidermidis)
What organisms are seen in injecting drug users?
- candida
- pseudomonas
How can infection of spinal canal lead to neurological damage?
- septic thrombosis leading to ischaemia
- compression of neural elements by abcess/inflammed tissue
- direct invasion of neural elements by inflammatory tissue
- mechanical collapse of bone leading to instability
