MSK Revision 4 Flashcards
Define cervical spondylisis [1]
Cervical spondylosis is a term used to describe degeneration of the vertebral column in the cervical (neck) region. It is otherwise known as cervical osteoarthritis.
NB: It’s important to note that cervical spondylosis is a normal part of ageing and many individuals with radiological evidence of the condition remain asymptomatic.
Give a brief overview of the pathophysiology of cervical spondylosis [5]
Initial Degeneration of intervertebral disc
- nucleus pulposus loses its water; decrease in disc height
- increased load on the annulus fibrosus, causing it to fissure and tear
Osteophyte formation
Degenerative Changes
- ligamentum flavum and posterior longitudinal ligament calficy leading to spina stenosis
Neural Compression:
- compression of nerve roots
Vasuclar compromise
Describe the clinical features of cervical spondylosis
Pain and/or stiffness in cervical region
Referred pain: retro-orbital, temporal, occipital, interscapular, upper limbs.
Signs of radiculopathy (most commonly affecting nerve roots C5 to C7)
* Unilateral neck, shoulder or arm pain, paraesthesia, or hyperaesthesia
* Diminished arm reflexes (triceps: C7, biceps: C5/C6, supinator: C5/C6).
NB - It is worth noting that many patients with degenerative change in the cervical region are asymptomatic.
Describe the investigations used for cervical spondylosis [3]
Generally cervical spondylosis is diagnosed clinically
Plain X-ray:
* Osteophyte formation
* Narrowed disc spaces
* Narrowing of intervertebral foramina
MRI
What are the differences and how do you differentiate between cervical spondylosis and radiculopathy? [2]
Which test can you use? [1]
The pain pattern in cervical radiculopathy is typically more localised compared to cervical spondylosis, which often manifests as diffuse neck pain.
Positive Spurling’s test:
- neck extension and lateral rotation towards the symptomatic side exacerbates symptoms
How do you differentiate between cervical spondylosis and myelopathy? [2]
Cervical myelopathy:
* UMN lesions - hyperreflexia, clonus, and positive Babinski sign.
* Gait disturbance
* Neurofocal deficits
NB: Cervical Myelopathy results from spinal cord compression and is characterised by signs of upper motor neuron lesion
Which cancers metastasis to the bone? [5]
Breast (most common)
Lung
Prostate
Thyroid
Renal
Metastases to the bone are usually via [] spread.
prostate and breast, this is via the [] system
lung cancers usually spread via the [] system.
Metastases usually spread via the blood (haematogenous),
- prostate and breast, this is via the venous system.
- lung cancers usually spread via the arterial system.
Malignant cord compression most commonly occurs in the [] spine
Cervical
Thoracic
Lumbar
Sacral.
Malignant cord compression most commonly occurs in the [] spine
Cervical
Thoracic
Lumbar
Sacral.
Most cases of malignant cord compression (85-90%) occur secondary to metastatic extension from the [spinal anatomy]. This means pressure on the thecal sac tends occurs [direction].
Most cases of malignant cord compression (85-90%) occur secondary to metastatic extension from the vertebral bodies.
This means pressure on the thecal sac tends occurs anteriorly.
Why might renal function be impaired in neoplastic spinal cord compression? [2]
due to underlying cancer such as in myeloma or prostate cancer if this is causing obstructive uropathy.
Describe the managment plan for neoplastic spinal cord compression [5]
Mobilisation:
- nursed supine and central spine alignment should be maintained.
Corticosteroids:
- immediate start on dexamethasone (reduces oedema helping to relieve compression) continued till a definitive treatment plan is made.
Analgesia
Sphincter function (bladder and bowel incontinence) needs to be assessed for daily
- Urinary catheterisation may be required for acute urinary retention.
Venous thromboembolism (VTE) prophylaxis due to cancer and immobility
Within 24 hours:
- Radiotherapy (external beam radiotherapy; stereotactic body radiotherapy) can be adjuvant or stand alone therapy
- surgical decompression and reconstruction, vertebroplasty and kyphoplasty
Which scoring system is used to determine prognosis (and therefore suitability for surgical intervention)? [1]
revised Tokuhashi scoring system:
* Overall health
* The number of non-vertebral bone metastases
* The number of vertebral metastases
* The number of metastases to other internal organs
* Primary cancer
* Neurological deficit
Each parameter is scored 0-2
Describe the clinical features of bone metastases [5]
Pain
- Classically wakes people from sleep AND described as gnawing pain like a toothache
Weight loss
Reduced mobility
Pathological fracture
Symptoms of hypercalcaemia
- when hypercalcaemia is found, 80% of patients are found to have metastases.
- muscle weakness, fatigue, and bone pain. Gastrointestinal issues like nausea, vomiting, constipation, and abdominal pain are also common. Individuals may experience increased thirst and frequent urination due to kidney involvement, and in severe cases, kidney stones or kidney dysfunction can occur. Neurologically, people with hypercalcemia may feel confused, lethargic, or experience difficulty concentrating and headaches
Which investigational technique should be used to investigate for bone mets. [1]
Describe what results might indicate bone mets [2]
Bone scintigraphy
- increased uptake of the Technetium-99 or it is asymmetrical
- If the kidneys and bladder are not seen on the scan, this is a worrying sign and may be due to a severe bone disease or bone metastases which are taking up all of the Technetium-99 so none is needed to be excreted
What is the bulbocavernosus reflex and why is it useful? [1]
squeezing the penis or the clitoris in a patient and monitoring the internal and external anal sphincter contraction in response
- useful test for checking whether the patient is in spinal shock after spinal trauma
- During the phase of shock, the bulbocavernosus reflex is absent and its return indicates the end of spinal shock.
What is the Lazarevic’s sign? [1]
Lazarevic’s sign is the positive result of a straight leg raise, which indicates an underlying disc herniation, most likely at the L5 level.
Describe the typical presentation of Achilles tendinopathy [5]
- Posterior ankle pain, often severe and exacerbated by physical activity or prolonged standing.
- Pain on palpation of the Achilles tendon.
- Swelling and thickening of the Achilles tendon, which may also feel warm to the touch.
- Pain or aching in the Achilles tendon or heel, with activity
- Stiffness
- Tenderness
- Swelling
- Nodularity on palpation of the tendon
How do you differentiate Achilles tendinopathy from Achilles tendon rupture? [1]
Simmonds’ calf squeeze test:
- patient to lie prone with their feet over the edge of the bed
- feel for a gap in the tendon and gently squeeze the calf muscles if there is an acute rupture of the Achilles tendon the injured foot will stay in the neutral position when the calf is squeezed.
Where exactly does Achilles tendon rupture occur? [1]
rupture usually occurs 4-6 cm above the calcaneal insertion in hypovascular region
What is the role of the plantar fascia? [1]
Which structures in the foot does it attach to? [2]
Plantar fascia (or aponeurosis) is a band of fibrous tissue that acts as a shock absorber providing stability within the foot and cushioning for force transmitted through the lower limbs.
Attache the calcaneus, travels along the sole of the foot and connects to the flexor tendons of the toes
Describe a clinical test can perform to diagnose PF [1]
Positive ‘windlass test’ (sensitivity 31.8%, specificity 100%):
- if there is pain at the heel area when the toes are passively dorsiflexed (upwards)
What is meant by fat pad atrophy? [1]
Thinning and degeneration of the fat pad of the heel (soft tissue layer in between the skin and the heel bone)
This makes the heel bone more vulnerable to repetitive microtrauma. This can lead to chronic inflammation, bruising, swelling and pain within the heel bone.
Describe what is meany by Morton’s neuroma [1]
Morton’s neuroma refers to the dysfunction of a nerve in the intermetatarsal space (between the toes) towards the top of the foot. The abnormal nerve is usually located between the third and fourth metatarsal.
What is Mulder’s click? [1]
Mulder’s click:
- one hand tries to hold the neuroma between the finger and thumb.
- The other hand squeezes the metatarsals together.
- A click may be heard as the neuroma moves between the metatarsal heads
What creates the Achilles tendon? [1]
The confluence of soleus muscle tendon with medial and lateral gastrocnemius tendons [1]
