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MSS > MSS23 Introduction To Spinal Cord Nerve Compression Disorders > Flashcards

MSS23 Introduction To Spinal Cord Nerve Compression Disorders Flashcards

1
Q

Cauda equina (horse tail)

A

Lumbar nerve root (usually starts from L2)

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2
Q

Claudication

A

**Impairment in walking, or pain, discomfort, numbness, or tiredness in the legs that occurs during walking or standing and is **relieved by rest

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3
Q

Sciatica

A

Clinical symptom:

Pain going down the leg from the lower back

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4
Q

Radiculopathy

A
  • Dysfunction of single nerve root / pinched nerve (usually Lumbar)
  • Lower motor neuron lesion
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5
Q

Myelopathy

A
  • Dysfunction of spinal cord (Cervical / Thoracic)

- Upper motor neuron lesion

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6
Q

History taking

A
  1. Pain
    - character
    - aggravating / relieving factors
    - location
    - severity
  2. Numbness
    - sensory fibres of nerve roots / spinal cord
  3. Weakness
    - motor fibres / spinal cord
  4. Balance
    - proprioception, severe weakness
  5. Sphincter control
    - bowel / bladder
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7
Q

Pathoanatomy of lumbar disc herniation

A

Stages:

  1. Protrusion
  2. Prolapse (nucleus pulposus 就出)
  3. Extrusion (nucleus pulposus 出左)
  4. Sequestration (separated / 隔離)
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8
Q

Anatomy of vertebral column

A

3 levels of vertebra:

  1. Pedicle (最高)
  2. Intermediate / Foramen (intervertebral: where nerve root exits)
  3. Disc (最低: ∴ compression on cord only leads to symptoms of lower levels since nerve root already exited)

3 section (left to right):

  1. Extraforaminal
  2. Foraminal
  3. Lateral recess (compression on lower level traversing nerve root)
  4. Central
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9
Q

***Causes of Lumbar spinal stenosis

A
  1. Dural sac and nerve root compression
  2. IV disc herniation
  3. Osteophytes
  4. Facet joint hypertrophy
  5. Ligamentum flavum hypertrophy
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10
Q

Spinal cord vs Nerve root

A

Spinal cord: CNS (usual injury site: Cervical and Thoracic region)

Nerve root: Initial segment of nerve which leaves the CNS (i.e. PNS) (usual injury site: Lumbar region)

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11
Q

(Surgery to decompress lumbar spine)

A
  1. Enter through central region
  2. Excise ligamentum flavum
  3. Retract nerve root
  4. Take out intervertebral disc fragments
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12
Q

Cervical spine anatomy

A

5 articulations between adjacent cervical vertebrae:

  • IV disk
  • 2 Facet joints
  • 2 Uncovertebral joint (兜 in body)

Borders of intervertebral foramina:

  • Superior: pedicle of vertebra above
  • Inferior: pedicle of vertebra below
  • Posterolaterally: facet joint
  • Antermedially: uncovertebral joint, IV disk
  • 7 cervical vertebra
  • 8 cervical nerve roots

Unlike Lumbar / Thoracic region:

  • Cervical nerve root exits above its vertebra:
  • -> C1 root exits above C1
  • -> C8 root exits between C7/T1
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13
Q

Cervical radiculopathy

A
  • Root irritation
  • ***Dermatomal
  • Sharp pain + Tingling / burning sensation
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14
Q

Cervical myelopathy

A
  • Cord dysfunction

Causes:

  1. Protruding disk
  2. Osteophyte
  3. OPLL (Ossification of the Posterior Longitudinal Ligament)
  4. Deformed uncovertebral process
  5. Facet joint dislocation (can lead to serious cord injury –> tetraplegia)
  6. Ligamentum flavum problem
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15
Q

(Surgery to decompress cervical spine)

A
  1. go through neck muscle e.g. SCM
  2. go through deep cervical fascia (between SCM and strap muscle)
  3. surrounding structures: carotid sheath, trachea, esophagus
  4. expose prevertebral fascia and longus colli muscle
  5. decompress / remove IV disk
  6. tricortical graft to stabilize IV region
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16
Q

***Descending vs Ascending Tracts

A

Descending tract (Motor)

  1. Lateral corticospinal tract
    - main voluntary motor
    - upper extremity motor
    - pathways more medial/central
    - 最出–>最入: control Sacral –> Lumbar –> Thoracic –> Cervical
  2. Ventral corticospinal tract
    - voluntary motor

Ascending tract (Sensory)

  1. Dorsal columns (posterior funiculi)
    - deep touch
    - proprioception
    - vibratory
  2. Lateral spinothalamic tract
    - pain
    - temperature

(3. Ventral spinothalamic tract)
- light touch

17
Q

Central cord syndrome

A

Etiologies:

  • **1. Trauma (esp. with cervical arthritis, older patients worse prognosis)
    2. Spondylotic myelopathy
    3. Syringomyelia (cyst within cord)
    4. Neoplasm: metastatic, glial, lymphoma

Symptoms:

  1. Sensory loss
    - loss in pain, temperature > posterior column sensation
    * **2. Weakness: Arms worse than Legs (since cervical pathways more medial in LCT)
  2. May occur in absence of spinal fracture
18
Q

Brown-Sequard: Hemicord (one side of cord) injury

A

Etiologies:

  • **1. Penetrating trauma
    2. Radiation
  • **3. Decompression sickness
    4. Multiple sclerosis

Symptoms:

  1. Ipsilateral loss
    - weakness
    - position sense
  2. Contralateral loss
    - pain, temperature
    - rarely typical

Prognosis:

  • 75-90% ambulate on discharge
  • 70% independent ADL
  • 80% bladder, bowel continent
19
Q

Arterial supply to vertebral column

A
  • ***Segmental arteries from vertebral, intercostal, lumbar arteries
  • -> anastomosing spinal branches
  • Rich supply of vessels in region of vertebral end plates (transition region between body and IV disc)

(- vessels do not penetrate cartilaginous end plate even in infancy

  • IV disc: Avascular, obtain nutrient by diffusion from tissue fluid)
20
Q

Blood supply to spinal column

A
  1. 1x **Anterior spinal artery
    - supply Whole cord anterior to posterior grey column
    - formed by union of 2 spinal arteries (from **    Vertebral artery) at foramen magnum
    - Midline vessel lies on ***Anterior median fissure
    - run length of cord (become small / absent in thoracic region)
  2. 2x **Posterior spinal artery
    - supply Grey + White posterior column
    - arise from **    Posterior inferior cerebellar artery / ***Vertebral artery above foramen magnum
    - descend from level of foramen magnum –> form 3 longitudinal channels
    - run through and behind posterior rootlets for length of cord
    - some anastomoses between 2 vessels
  3. **Radicular arteries
    - Most characteristic feature:
    - -> Variability in no., position
    - -> blood may flow up/down the cord
    - largest: **    Artery of Adamkiewicz: usually arise from left T10 (T5-L5)
    - highly important contribution to reinforce longitudinal trunks
    - most disappear as fetus grow
    - remaining anastomise with anterior/posterior spinal arteries
    - supplemented at variable levels by anastomoses with variable no. of radicular arteries
21
Q

Anterior cord syndrome

A

Etiology:

  • deep, difficult to damage
    1. Ischaemia of anterior spinal artery (territory)
    2. Fracture fragments
    3. Retro-pulsed disc

Symptoms:

  1. Loss of ***motor function
  2. Loss of pain sensation
  3. Loss of temperature sensation
  4. Position sense preserved

Prognosis:

  • 10-20% muscle recovery
  • poor muscle power and coordination
22
Q

Posterior cord syndrome (least common)

A

Etiology:

  1. Damage of posterior spinal artery
  2. Diffuse artherosclerosis (deficient collateral perfusion)
  3. B12 deficiency

Symptoms:

  1. Loss of ***position sense
  2. Motor, pain, temperature preserved

Prognosis:

  • better than anterior syndrome
  • poor ambulation prospect due to proprioceptive deficit
23
Q

Venous drainage of vertebral column

A

***Spinal venous plexus

Significance:

  • **Batson’s plexus:
  • Pelvis venous drainage communicate with Spinal venous plexus
  • Pelvic tumours and infections –> spread to spinal column
24
Q

Pathology of vertebral column

A

Blood borne infection (starts in vertebral end plate)

  • -> suppurative inflammation
  • -> ***bone necrosis, collapse
  • -> spread to adjacent IV disc + vertebra
  • -> ***paravertebral abscess
  • -> ***epidural abscess
  • -> infection of meninges, spinal cord
  • -> occasionally involve posterior elements
25
Q

Pyogenic spondylitis (broad term)

A

focus of Osteomyelitis in vertebral body

  • -> spread into IV disc by perforating end plate
  • -> spread in disc and adjacent vertebral body
  • -> **destruction of disc + **narrowing of IV space
26
Q

TB spine features

A
  1. Multiple levels
  2. More bony involvement
  3. Subligamentous spread
  4. ***Skip lesions
27
Q

Spinal metastasis

A

Mechanism (Venous system):
1. Breast via azygous system
2. Lung via pulmonary vein and arterial system
3. **Prostate via pelvic plexus
- **Batson’s plexus: connection between peri-prostatic plexus and vertebral venous plexus
—> network of longitudinal valveless veins that anastomose with the vertebral marrow and epidural venous channels
—> ↑ intra-abdominal pressure —> divert blood into the epidural venous plexus —> pathway of metastatic embolization

Pathway of local spread:
- Venous sinusoids of vertebral body
—> Barriers to local spread: ALL, PLL, Ligamentum flavum, Periosteum, endplates, annulus
—> Tumour cells invade at sites of vascular perforations in barriers

Diagnosis:
Plain radiographs
- **destruction not evident until 30-50% spongy bone destroyed
- **Winking owl sign classic (Absence of pedicle on radiograph, normally can see pedicle)

MSS (32 decks)

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