MET SC Compression + Spinal Infections

Question 1

What should you first exclude in a patient presenting with back pain?

Answer 1

• Abdominal/retroperitoneal causes (AAA, Pancreatitis, Malignancy)
• Spinal trauma
• Spinal infection
• Spinal tumour

Question 2

What is the commonest tumour in bone?

Answer 2

Myeloma

Question 3

What is the commonest bone tumour?

Answer 3

Osteosarcoma

Question 4

What are the red flags?

Answer 4

• <16 yrs or >50 yrs with NEW onset pain
• Unwell/unexplained weight loss/unexplained fevers
• Past history of cancer, recent serious illness/infection
• Previous long standing steroid use, HIV/AIDs, end stage renal disease, osteoporosis, pagets disease, alcohol/drug abuse
• Widespread neurological deficit
• Non-mechanical pain
• Thoracic pain
• Spinal deformity

Question 5

What should be done if suspected CES/MSCC?

Answer 5

Urgent referral
Cauda equina syndrome
Metastatic spinal cord compression

Question 6

What age are primary spinal tumours normally benign?

Answer 6

<21

Question 7

What is the common site for benign and malignant primary spinal tumours?

Answer 7

• Posterior column - benign

- Anterior column - malignant

Question 8

What is the presentation of spinal tumours?

Answer 8

• Pain - not relieved by rest, intensifies @ night
• Neurological compression - symmetrical, bladder/bowel loss = late feature
• Spinal cord compression - kyphosis after vertebral collapse

Question 9

What are the primary sites of metastasis?

Answer 9

Breast 
Lung 
Prostrate 
Lymphoma 
Kidney 
Myeloma 
Colon

Question 10

How are tumours spread?

Answer 10

1. Bloodstream or lymphatics
   - breast via azygous venous system
   - prostate vie pelvic venous plexus
   - lung via segmental arteries
2. Batson
   - paravertebral + venous plexus
3. Direct

Question 11

What are the red flags for MSCC?

Answer 11

Weight loss
Fatigue
Anorexia
Haemoptysis
Haematuria
Melena
Haematemesis 
Smoking

Question 12

What are indications for surgery in MSCC?

Answer 12

• Progressive/ impending neurological deficit
• Spinal instability/collapse/deformity
• Paralysed < 24 hrs
• Intractable pain (paralysed > 24hrs)
• Histological confirmation
• Growing tumour resistant to non-op measures
• Relapse

Question 13

Why are steroids used in MSCC?

Answer 13

• Reduce oedema

- Dexamethasone

Question 14

What is the prognosis of MSCC?

Answer 14

6 months

Question 15

What is the presentation of spinal infections?

Answer 15

• Acute fever + pain
• Vague symptoms, chronic illness
• Back pain (most common lumbar)
• Neurology

Question 16

What are the most common causes of spinal infections?

Answer 16

1. Staph

2. Enterobacter

Question 17

What is the typical patient with spinal infections?

Answer 17

D diabetic/ druggie
I immuno/ immigrant 
S steroids/ spinal surgery
G genitourinary
R renal/ rheumatoid 
A adolescents 
C cardiac issues 
E elderly

Question 18

What are the complications of spinal infections?

Answer 18

• Ongoing infection + sepsis
• Paralysis
• Deformity (bone infection = soft bone = deformity)
• Pain + instability

Question 19

Where are epidural abscess most commonly located?

Answer 19

Thoracic

Question 20

What are the indications for surgery in spinal infection?

Answer 20

• Open biopsy required for diagnosis
• Drain of abscess
• Decompress SCC with neuro deficit
• Correct progressice or unacceptable spinal deformity/instability

Question 21

What are the goals of surgery?

Answer 21

• Complete debridement of all cells non-viable + infected tissue
• Decompress neural elements
• LT stability through fusion
• Decompress/ realign/ stabilize

Question 22

What causes surgical site infections?

Answer 22

1. Direct inoculation @ surgery
2. Contamination early post op
3. Contamination haematogenous seeding

Causes by staph > enterococcus > e.coli > pseudomonas