Mini Symposium - Spine Flashcards
1
Q
What are orthopaedic causes of unsteady gait?
A
Myelopathy (slipped disc)
L5 radiculopathy
Antalgic gait caused by sciatica
2
Q
How can you pick up unsteady gait/problems with balance?
A
Dynamic Romberg’s test
3
Q
What spinal segments maintain continence?
A
S234 supply the doors
4
Q
Distinguish between an upper motor neuron problem and a lower motor neuron problem
A
UMN - in spinal cord
LMN - in peripheral nerve after it’s left spinal cord
5
Q
What are the clinical features of an L5 radiculopathy?
A
High stepping gait (compensatory high lifting of leg to prevent foot dragging as there is weakness of dorsiflexion)
6
Q
What is sciatica?
A
Pain/tingling/numbness/weakness in back, bottom of legs, feet/toes that is usually worse on physical activities
Not just back pain!!
7
Q
What can cause sciatica?
A
Degenerative disc disease and herniation
Tumour
Trauma
Infection
Trapped nerve
–> compression of sacral nerves/sciatic nerve
8
Q
How can you test for L4 and 5 function?
A
Get patient to walk on heel
9
Q
How can you test the gastrocnemius and soleus function (S1)?
A
Walk on tiptoes
10
Q
How can you test for sciatica?
A
Straight leg raise will recreate sciatica pain
11
Q
What two differentials must you exclude when people present with seemingly orthopaedic spine problems?
A
Vascular problems (check pulses) Hip arthritis
12
Q
How can you test for protrusions at L2-3 and L3-4?
A
Femoral stretch test - passively flex knee to thigh and extend hip
+ve if anterior thigh pain
13
Q
What can cause focal bony tenderness?
A
Trauma
Tumour
Infection
14
Q
Where does muscle attach on to vertebrae?
A
Spinous processes and transverse processes
15
Q
What are the lordoses and kyphoses of the spine?
A
Lumbar and cervical lordoses
Thoracic and sacral kyphoses
16
Q
Which of the lordoses and kyphoses are most mobile?
A
Lordoses
17
Q
What is the majority of spinal surgery for?
A
Releasing a trapped nerve
18
Q
What movements occur at the spine?
A
Depends where it is
Flexion, extension, lateral flexion, rotation
19
Q
How many vertebrae are there?
A
33 in total 7 cervical 12 thoracic 5 lumbar 5 sacral variable coccygeal
20
Q
What is the coronal alignment of the spine?
A
Should be straight
If not - ?scoliosis
21
Q
What is the long group of muscles on the back?
A
Erector spine - consists of spinalis, longismus, iliocostalis
22
Q
What is the function of the erector spinae muscles?
A
Erect the spine and maintaining the spine in the erect position
23
Q
Where do spinal nerves leave the spine?
A
Via foramen BELOW the corresponding pedicle (apart from C8 - as only 7 lumbar vertebrae)
24
Q
Where does the spinal cord end?
A
As conus medullaris at L1/2
25
Define dermatome
Sensory area of skin supplied by a single spinal nerve
26
What is the L2 dermatome?
Speedo region
27
Define myotome
Group of muscle supplied by one spinal segment
28
What are the upper limb myotomes?
```
C5 - shoulder abduction (deltoid)
C6 - biceps (elbow flexion)
C7 - wrist extension (triceps)
C8 - finger flexion (FDS and FDP)
T1 - finger abduction (interossei)
```
29
What are the lower limb myotomes?
```
L2 - hip flexion (iliopsoas)
L3/4 - knee extension (quadriceps)
L4 - ankle dorsiflexion (anterior tibialis)
L5 - big toe extension (EHL)
S1 - ankle plantarflexion (gastroc)
```
30
What is a useful rhyme to remember the myotomes associated with different reflexes in the limbs?
1, 2 buckle my shoe (ankle jerk - S1, 2)
3, 4 kick the door (patellar tendon L3-4)
5, 6 pick up sticks (brachioradialis/biceps - C5-6)
7, 8 close the gait (triceps C7-8)
31
15% of people with fractures or dislocations of the spine will have what?
Spinal cord injuries
32
In what gender and age group do SCI occur more often?
Males
| Peak is 20-29 years
33
What are the most common causes of SCI?
```
Degenerative orthopaedic causes
Tumours
Spinal cord stroke
Transverse myelitis
Thoracoabdominal aortic aneurysm
FALLS MOST COMMON
```
34
What is the difference between a complete and an incomplete SCI?
Complete = complete loss of sensation and motor function below SCI (no anal squeeze, acral sensation or chance of recovery)
Incomplete = lesions of ascending/descending spinal tract where some function is present below site of lesion - better prognosis
35
What can cause an incomplete spinal lesion?
Trauma
Spinal compression
Occlusion of spinal arteries
E.g.s - central/anterior/posterior cord syndrome and brown sequard syndrome
36
What must you be aware of when diagnosing complete or incomplete SCI?
Patient may be in spinal shock - acute physiological loss or depression of spinal cord function for hrs-weeks after SCI) - lose all sensorimotor functions below level of injury
37
What is the ASIA classification?
Used to measure severity of SCI
Grade A - complete spinal injury (no sensory/motor function in S4-5)
Grade B - incomplete; sensory but no motor function below SCI (extending to S4-5)
Grade C - incomplete; motor function preserved below SCI, maj key muscles grade <3 (active RoM without gravity)
Grade D - incomplete; motor function preserved below SCI; maj key muscles grade >3 (full active RoM with gravity)
Grade E - normal sensation and motor function
38
What is tetra/quadriplegia?
Partial/total loss of use of all four limbs and the trunk
39
What is quadriplegia normally due to?
Cervical spine injury, e.g. cervical fracture
40
Why would you be really concerned about damaging C3, 4 or 5 nerve roots?
As they make up the phrenic nerve which supplies the diaphragm and therefore are responsible for breathing
41
What may you also see in quadriplegia?
Spasticity and other UMN signs if the damage is above L1
42
What is paraplegia?
Total/partial use of the lower limbs
43
What are the clinical features of paraplegia?
```
Arm function spared
Possible involvement of trunk
Motor/sensory impairment in thoracic/lumbar/sacral segements
Spasticity if above L1
Bowel/bladder affected
```
44
What may cause paraplegia?
Thoracic/lumbar fractures
45
What is central cord syndrome?
Injury to the central region of the spinal cord
Tends to be cervical central tracts affected
46
In which group of people is central cord syndrome more common?
Elderly with pre-existing degenerative changes (e.g. arthritic neck)
47
What is the aetiology of central cord syndrome?
Degenerative spine dx, traumatic disc herniation, various hyperextension injuries (e.g. whiplash)
48
Does central cord syndrome affect the arms or legs more?
More arms
(can still walk)
Still have perianal sensation and lower extremity power
49
What is anterior cord syndrome?
Damage to the anterior 2/3rd of spinal cord
50
What tends to cause anterior cord syndrome?
Reduced BP/occlusion of anterior spinal artery (e.g. arteriosclerosis, vasculitis, thrombosis)
Other causes: trauma (e.g. penetrating trauma), anterior compression fracture, hyperflexion injury w. vertebral instability, pathological compression (e.g. tumours)
51
What are the signs and symptoms of anterior cord syndrome?
Fine touch and proprioception preserved by profound weakness
52
What is brown sequard syndrome?
Damage to a hemisection of the cord
53
What are the aetiologies of brown sequard syndrome?
Tends to be penetrating injuries or disc herniation
54
What are the signs and symptoms of brown sequard syndrome?
Ipsilateral loss of proprioception, vibration, tactile discrimination below level of lesion
Contralateral loss of pain, temperature sensation below level of lesion
55
How do you manage SCI?
Prevent secondary injury - avoid HTN, hypovolaemia, inadequate BS, blood loss, immobilise patient, do ATLS resus, give appropriate Rx/surgical care
56
What is involved in the ABCD/ATLS of SCI?
Airway and C spine control
Breathing (ventilation and oxygenation)
Circulation - IV fluids, consider neurogenic shock
Disability - assess neurologic function, include PR and perianal sensation, log roll and document
ASIA assessment
57
What is neurogenic shock?
Response of the body to a spinal cord injury that leads to the disruption of the sympathetic system
58
What are the signs of neurogenic shock?
Hypotension
Bradycardia
Hypothermia
59
What can cause neurogenic shock?
Injuries above T6
60
What kinds of imaging can be used to diagnose SCI?
Xray
CTS good for bony anatomy
MRI - if neurological deficit or children
61
What are the clinical features of spinal shock?
Transient depression of cord function below level of injury
| --> flaccid paralysis, areflexia
62
What are causes of broken spinous processes?
Tends to be car accidents, fall or hyperflexion injuries
63
How do you manage broken spinous processes?
Surgical fixation for unstable fractures (mostly done from posterior with pedicle screws)
64
What are the long term managements for SCI?
```
SCI unit
Physio
OT
Psychological support
Urological/sexual counselling
```
65
What kind of joint is the IV disc?
Secondary cartilaginous
66
Hoes the IV disc get its nutrient?
Its avascular so relies on end plates of bone on either side
67
What is the structure of an IV disc?
Outer tough, cartilaginous annulus fibrosis
Inner, gelatinous nucleus pulposis (88% water, collagen and proteoglycans)
68
What is the purpose of the annulus fibrosis? How does its structure compensate for this?
Resists rotational movements as fibres run obliquely and alternatively between the layers
69
Define disc protrusion
Pressure on vertebrae causes nucleus pulposus to move and press against annulus fibrosis
This bulge can compress a spinal nerve and cause pain
70
Define disc herniation/prolapse
A tear in annulus fibrosis allows extrusion of nucleus pulposus and potential compression of spinal nerve
71
In what direct do discs tend to herniate and why?
Posteriolaterally due to the thin posterior longitudinal ligament
72
What can result from disc herniation?
Pressure on nerve root (radiculopathy)
| Pressure on the central canal (myelopathy)
73
Define disc extrusion
Through annulus but in continuity
74
Define sequestration
Desicated disc material free in canal
75
What are the most common symptoms of disc disease?
Radicular pain in dermatome of compressed nerve root, muscle weakness and loss of deep tendon reflexes
76
How can you diagnose a lumbar disc prolapse?
MRI will confirm diagnosis
77
What is involved in the normal ageing process of the IV discs?
Water content decreases
Disc space narrows
Degenerative changes on XRay (sclerosed, dehydrated)
Degenerative changes in the facet joint (can become misaligned)
78
What things will aggravate the normal ageing process of the IV discs?
Smoking, genetic predisposition, heavy manual work etc.
79
Define spondylolysis
Lytic defect in pars interarticularis, permitting forward slippage of superior vertebrae
80
Define spondylolisthesis
Vertebral body slips forward/backwards in relation to the vertebral body above it
81
How do you manage spondylolisthesis?
Conservative, lifestyle changes, surgery for persistent pain/nerve root entrapment
82
What is nerve root pain?
Pain/weakness/numbness in the nerve root distribution (radiculopathies) due to compression of the nerve root
83
What is the most common cervical disc prolapse?
C5/6
84
What are the least common disc prolapses?
Thoracic (most T11-12 in thoracic region, however)
85
What is the management for thoracic disc prolapses?
Don't do much unless impeding paralysis - in which case remove it
86
What are the most common lumbar disc prolapses?
L4/5 or L5/S1
87
L5/S1 IV disc prolapse affects what nerve and leads to what symptoms and signs?
S1
| Sensory loss over little toe and sole of foot, weakness in plantarflexion of foot and reduced/no ankle jerk
88
L4/5 IV disc prolapse affects what nerve and leads to what symptoms and signs?
L5
Sensory loss over great toe and first dorsal webbed space
Weakness in EHL
89
L3/4 IV disc prolapse affects what nerve and leads to what symptoms and signs?
Sensory deficit in medial aspect of lower leg
Motor weakness in quads
Knee jerk diminished/absent
90
Define cauda equina syndrome
Damage/compression of the cauda equina (incl. nerve roots below L2)
91
What are the aetiologies of cauda equina syndrome?
Central lumbar disc prolapse (most common)
Tumours
Trauma (burst, or chance fracture)
Spinal stenosis
Infection (epidural abscess)
Iatrogenic (surgical, manipulation, spinal epidural injection)
92
What are the clinical features of cauda equina syndrome?
Injury/precipitating event
Bilat buttock pain and leg pain, varying dysaesthesia/weakness
Bowel and bladder dysfunction (urinary retention +/- incontinence overflow)
PR exam - saddle anaesthesia, loss of perianal sensation, anal tone and anal reflex
93
When should you have a high index of suspicion for cauda equina syndrome?
Spinal post-op patients w. increasing leg pain and urinary retention
94
How do you investigate cauda equina syndrome?
Urgent MRI
| If CI - lumbar CT myelogram
95
What is the treatment for cauda equina syndrome?
Emergency surgery within 48h
| Remove disc, wash away haematoma, reconstruct vertebrae to take pressure off tumour etc. etc.
96
What is the prognosis of cauda equina syndrome?
Worse the later its treated
| Can result in permanent bladder and anal dysfunction and incontinence
97
Define spondylosis
Broad term used to describe degenerative changes of the spine that may cause irritation/damage to the nerve roots
98
Where do degenerative changes occur in spondylosis?
Facets, discs, joints, ligaments etc.
99
What is the pathophysiology of spondylosis?
Discs dehydrate --> facets become misaligned as disc height reduces --> misaligned vertebral canal --> myelopathy
Joints become arthritic and osteophytes appear putting pressure on nerves --> radiculopathies
Shrinkage of disc leads to ligamentum flavum buckling in and encroaching into the canal --> pressure on caudal equina (not caudal equina syndrome as it is slow changes)
100
What are the ligaments supporting the spine?
Anterior longitudinal ligament - along front of vertebral bodies, broad, strong
Posterior longitudinal ligament - along backs of bodies
Ligamentum flavum - between laminae
Interspinous and supraspinaous ligaments between the spinous processes
Intertransverse ligament between transverse processes
101
Define spinal claudication
Common symptom of spinal stenosis, causing impingement or inflammation of nerves coming off the spinal cord due to marked narrowing of the spinal cord
102
How can you distinguish between spinal and vascular claudication?
Usually bilateral radiation of buttocks/legs vs unilateral calf pain
Sensory dysaesthesia
Possible weakness (e.g. foot drop)
Takes several mins to ease after stopping walking
Walking downhill worse (as spinal canal smaller in extension), walking better uphill/ridding bike
103
Define spinal stenosis
Disease caused by narrowing of central spinal canal, lateral recess and/or neural foramen --> progressive nerve root compression
104
What tends to cause spinal stenosis?
Degenerative spinal changes (i.e. spondylosis and spondylolisthesis)
105
What is lateral recess stenosis?
Narrowing of the rear sides of the spinal canal
106
How do you treat lateral recess stenosis?
Nerve root/epidural injection or operative
107
What is central spinal stenosis?
Narrowing of the central canal
108
How do you treat central spinal stenosis?
Epidural steroid injection or surgery
109
What is foraminal spinal stenosis?
Narrowing as the nerve root is about to leave the transverse foramina
110
How do you treat foraminal spinal stenosis?
Nerve root/epidural injection or surgery
