Orthopaedics III

Question 2

What is meant by a radiculopathy? [1]

Answer 2

Radiculopathies are disorders affecting spinal nerves or nerve roots, leading to pain, numbness, weakness or difficulty controlling specific muscles.

They can occur in any part of the spine

Question 3

Describe the basic overview pathophysiology of radiculopathies [+]

Answer 3

Mechanical compression or inflammation of the nerve root due to herniated intervertebral discs, spinal stenosis or direct trauma.

This leads to oedema which further increases pressure on nerve root, causing neuronal damge

Get ectopic dishcarges in the demyelinated regions of the neurons

Demyelination also causes ephaptic transmission (abnormal cross-talk between sensory fibres that normally carry non-painful stimuli and painful stimuli)

The neuronal injury and subsequent inflammation lead to activation of nociceptors - sensory receptors that respond to potentially damaging stimuli by sending “possible threat” signals to the spinal cord and brain. This process is termed peripheral sensitisation

Continued nociceptive input to the central nervous system can induce changes in the dorsal horn neurons leading to an increased response to peripheral stimuli. This is referred to as central sensitisation and it results in heightened pain sensitivity (hyperalgesia) or pain response from normally non-painful stimuli (allodynia).

Question 4

Describe the sensory [4] and motor [3] symptoms of radiculopathies

Answer 4

Sensory:
- Pain: sharp, shooting, or electric-like and follows a dermatomal distribution - hallmark symptom
- Paresthesia
- Numbness
- Hypersensitivity

Motor SymptomsL:
- Muscle Weakness: Depending on which nerve root is compressed, patients may experience weakness in specific muscle groups
- Muscle Atrophy: In chronic cases where there has been ongoing nerve compression
- Fasciculations/Twitching

Question 5

In clinical practice, the most common radiculopathies are those affecting the lumbosacral nerves between []

Answer 5

In clinical practice, the most common radiculopathies are those affecting the lumbosacral nerves between L1-S4

Question 6

Describe the presentation for each lumbosacral radiculopathy (L1; L2-4; L5; S1)

Answer 6

L1:
- sensory changes in the inguinal region

L2-4:
- acute back pain that radiates around the anterior thigh
- sensory changes may be present over the anterior thigh and medial lower leg

L5:
- acute back pain that radiates down the lateral aspect of the leg to the foot
- sensory changes may be present over the lateral aspect of the lower leg and dorsum of the foot.
- Motor weakness is seen in foot dorsiflexion, big toe extension, and foot inversion/eversion

S1:
- acute back pain that radiates down the posterior aspect of the leg into the foot.
- sensory changes may be present over the posterior leg and lateral foot.
- weakness may be present in hip extension and knee flexion. There may be a loss of the ankle reflex

Question 7

Several manoeuvres can be completed to determine whether the pain is radicular in origin (L1-S1), which includes [2]

Answer 7

Straight leg raise for L5/S1 radiculopathy:
- worsening radicular pain on raising the leg with the knee extended. Pain should be relieved if the knee is flexed

Reverse straight leg raise for L2-4 radiculopathy:
- worsening radicular pain on extending the leg with the patient prone

Question 8

Describe the classic presentation of C5-C8 radiculopathie

Answer 8

C5 radiculopathy:
- associated with pain in the neck, shoulder, and scapula.
- sensory loss is usually seen in the lateral aspect of the upper arm
- weakness in shoulder abduction. Biceps and brachioradialis reflexes may be affected

C6 radiculopathy:
- associated with pain in the neck, shoulder, scapula, and lateral arm, forearm, and hand.
- Sensory loss in the lateral forearm, thumb, and finger (pointing a gun).
- Weakness may be seen in elbow flexion and supination/pronation. Biceps and brachioradialis reflexes may be affected

C7 radiculopathy:
- associated with pain in the neck, shoulder, hand, and middle finger.
- sensory loss in the palm, middle, and index finger.
- weakness is usually seen in elbow and wrist extension. Triceps reflex may be affected

C8 radiculopathy:
- associated with pain in the neck, shoulder, medial forearm, hand, and 4th/5th fingers.
- sensory loss in the medial forearm, hand, and 4th/5th digits
- weak finger movements

Question 9

There are several important signs may be present that are suggestive of the involvement of the cervical cord (i.e. cervical myelopathy). What are they? [4]

Answer 9

Lhermitte phenomenon:
- shock-like paraesthesia radiating down the spine and towards the legs that occur on neck flexion

Gait disturbance

Upper motor neuron signs in the lower limbs (e.g. increased tone, weakness, clonus, upgoing plantar)

Bladder/bowel dysfunction

Question 10

How do you investigate radiculopathies? [+]

Answer 10

Imaging:
- MRI: first line as gives high-resolution images of the spinal cord, nerve roots, and surrounding structures
- CT
- X-ray - can reveal osteophytes causing compression

Nerve conduction: assess the speed at which nerves transmit signals.

EMG: measures electrical activity within muscle fibres, providing insights into how well muscles respond to nerve stimulation.

Lab tests:
- Serology - if vasculitis or Lyme disease the cause
- CSF analysis

Question 11

How do you differentiate between radiculopathies and peripheral neuropathies? [2]

Answer 11

Peripheral neuropathies typically present with symmetrical symptoms in a ‘stocking-glove’ distribution, whereas radiculopathy usually presents with asymmetrical symptoms in a dermatomal pattern.

Peripheral neuropathy does not usually have an accompanying localised spinal pain

Question 12

How do you differentiate between radiculopathies and myelopathies? [3]

Answer 12

• Magnetic resonance imaging (MRI) of the spine remains the gold standard for distinguishing between these two conditions.
• Myelopathic signs are generally more diffuse, while radicular symptoms follow specific dermatomes or myotomes.
• Upper motor neuron signs such as spasticity and hyperreflexia suggest a myelopathy rather than a radiculopathy which is characterised by lower motor neuron signs like flaccidity and hyporeflexia.

Question 13

Describe the management plan for radiculopathies

Answer 13

Pharmalogical treatment:
* NSAIDs are the first-line treatment for pain relief
* Corticosteroids may be used orally or via epidural injections in cases resistant to NSAIDs - this is both diagnostic and therapeutic. If this works to relieve pain, then know its the correct cause of pain
* Gabapentinoids, tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs) can be considered for neuropathic pain

Physical Therapy
Lifestyle Modifications
Surgical Interventions:
* Open discectomy or microdiscectomy
* Disc fusion
* Laminectomy

Question 14

What are general causes of neck pain [4]

Answer 14

• Muscle or ligament strain (e.g., poor posture or repetitive activities)
• Torticollis (waking up with a unilaterally stiff and painful neck due to muscle spasm)
• Whiplash (typically after a road traffic accident)
• Cervical spondylosis (degenerative changes to the vertebrae

Question 15

The spinal nerves [] – [] come together to form the sciatic nerve.

Describe the path of sciatic nerve [3]

Answer 15

The spinal nerves L4 – S3 come together to form the sciatic nerve.

Pathway:
- sciatic nerve exits the posterior part of the pelvis through the greater sciatic foramen, in the buttock area on either side
- It travels down the back of the leg.
- At the knee, it divides into the tibial nerve and the common peroneal nerve.

Question 16

Where does the sciatic nerve supply sensation to? [2]
Where does the sciatic nerve supply motor function to? [3]

Answer 16

The sciatic nerve supplies sensation to the lateral lower leg and the foot.

It supplies motor function to the posterior thigh, lower leg and foot.

Question 17

What are the three main causes of sciatica? [3]

Answer 17

Herniated disc
Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
Spinal stenosis

Question 18

Describe a test can perform to diagnose sciatica [1]

Answer 18

The sciatic stretch test:
- The patient lies on their back with their leg straight.
- The examiner lifts one leg from the ankle with the knee extended until the limit of hip flexion is reached (usually around 80-90 degrees).
- Then the examiner dorsiflexes the patient’s ankle.
- Sciatica-type pain in the buttock/posterior thigh indicates sciatic nerve root irritation.
- Symptoms improve with flexing the knee.

Question 19

What is the STarT Back Screening Tool? [1]

How does this tool inform management plans? [3]

Answer 19

Tool used to stratify the risk of a patient presenting with acute back pain developing chronic back pain.

This helps guide the intensity of the initial interventions (e.g., referral for group exercises, physiotherapy and cognitive behavioural therapy).

• Low risk patients: can be managed with reassurance and encouragement to remain active, early managed return to work and simple analgesia
• Medium risk patients: should be managed as per low risk in addition to offering a referral to physiotherapy
• High risk patients: should be referred to psychologically informed physiotherapy.

Question 20

How do you manage generalised back pain? [+]

Answer 20

First line analgesia:
- NSAIDS (+PPI)
- Codeine / dihydrocodeine/ tramadol

Other management strategies
For patients at higher risk of poor outcome, NICE recommends considering the following:
* Referral to a group exercise programme
* Referral to physiotherapy for manual therapy
* Referral for CBT as part of a treatment package including exercise +/- manual therapy

Radiofrequency denervation
NICE advises consider referral for radiofrequency denervation in patients with chronic back pain where:
* The patient has failed to respond to non-surgical treatment
* The main source of pain is thought to be related to structures supplied by the medial branch nerve
* The pain is rated as 5 or more on a visual analogue scale or equivalent

Question 21

What is the managment plan if muscle spasms are thought to be the primary issue causing back pain? [1]

Answer 21

A short course (2-5 days) of diazepam may be used. Initially this should be 2mg diazepam to be taken as required up to three times a day. The dose can be titrated up to 5mg tds if required.

Question 22

Describe the management plan of sciatica [3]

Answer 22

NSAIDS first line
Codeine / dihydocodeine
Amitriptyline or Duloxetine (but not gabapentin or pregabalin)

Question 23

Describe the anatomy of the cauda equina [1]

Answer 23

The cauda equina is a collection of nerve roots that travel through the spinal canal after the spinal cord terminates around L2/L3.

The spinal cord tapers down at the end in a section called the conus medullaris.

Question 24

Describe the innervation the nerve roots of the cauda equina supply [4]

Answer 24

• Sensory and motor innervation to the lower limbs
• Sensory innervation of the saddle area
• Motor innervation to the anal sphincters
• Parasympathetic innervation of the bladder

Question 25

**Conus medullaris syndrome (CMS)**: The conus medullaris is the tapered end of the spinal cord which spans from T12-L2. Injuries to the lumbar vertebrae may result in compression of the conus medullaris, resulting in symptoms. How would you differentiate this to CES? [2]

Answer 25

CMS differences: **Sudden onset** (typically after injury to the back); **Patients have a mix of upper and lower motor neurone signs** with hyperreflexia, weakness and fasciculations often being present.

Question 26

Which patients with CES would not be suitable for sugery? [3] How would you treat them instead? [3]

Answer 26

Inflammatory disease such as **late stage ankylosing spondylitis** * These patients may benefit from **steroids** **Infection** * These patients will be treated with **antibiotics** **Spinal neoplastic disease** which is not suitable for surgical removal or where surgical removal was incomplete * These patients should be given **IV** **dexamethasone** and be evaluated for chemo-radiotherapy

Question 27

Describe what is meant by (lumbar) spinal stenosis [1] What are the primary [2] and secondary [4] causes?

Answer 27

Narrowing of the spinal canal in the lumbar region **Primary Causes** * **Congenital Stenosis:** This is an inherent condition where individuals are born with a narrow spinal canal. It is relatively rare but poses a significant risk for developing LSS. * **Achondroplasia**: This genetic disorder impairs bone growth, leading to dwarfism. Individuals with achondroplasia often exhibit abnormal spine development, predisposing them to LSS. **Secondary causes** - **Degenerative Changes**: Age-related degenerative changes are the most common cause: OA; disc degeneration, and facet joint hypertrophy - **Spondylolisthesis**: The forward displacement of one vertebra over another - **Trauma** - **Tumours**

Question 28

What are the three types of spinal stenosis [3]

Answer 28

**Central stenosis** – narrowing of the central spinal canal **Lateral stenosis** – narrowing of the nerve root canals **Foramina stenosis** – narrowing of the intervertebral foramina

Question 29

Describe the general presentation of LSS [5]

Answer 29

**Neurogenic claudification** - bilateral, symmetrical buttock or lower extremity pain, numbness, and weakness that is exacerbated by lumbar extension **Radicular pain** - pain in dermatomal pattern - accompanied by paraesthesia, numbness, or weakness **Back Pain:** - Often a combination of factors including degenerative disc disease, facet joint osteoarthritis, and ligamentum flavum hypertrophy. **Motor and sensory deficits:** - Specific to affected nerve root **Cauda Equina Syndrome**

Question 30

TOM TIP: The important thing for your exams is to spot the typical symptoms of intermittent neurogenic claudication. At first glance, they are similar to peripheral arterial disease. How do you differentiate between them in an exam question?

Answer 30

The exam question might specify that the **peripheral pulses** or the ankle-brachial pressure index (**ABPI**) are **normal**, in which case the **diagnosis** is more likely to be **spinal stenosis.** Additionally, patients with **spinal stenosis** are more likely to struggle with **back pain**, whereas back pain is not a feature of peripheral arterial disease.

Question 31

How does central lumbar stenosis differ to lateral and foramina stenosis [1]

Answer 31

**Lateral stenosis and foramina stenosis in** the lumbar spine tends to cause symptoms of **sciatica** (*unilateral pain from the buttock radiating down the back of the thigh to below the knee or feet.*) **Intermittent neurogenic claudication** is a key presenting feature of lumbar spinal stenosis with central stenosis. It is sometimes referred to as pseudoclaudication. Typical symptoms are:

Question 32

How do you differentiate CES and spinal stenosis? [1]

Answer 32

Symptoms of **spinal** **stenosis** tend to have a **gradual onset**, as opposed to **cauda equina syndrome** or **sudden** disc herniation with cord compression

Question 33

What is piriformis syndrome and how does it differentiate with LSSS? [1]

Answer 33

**Piriformis Syndrome** - neuromuscular disorder occurs when the **piriformis muscle** **compresses** the **sciatic nerve** - **piriformis syndrome** often presents **unilaterally** with symptoms **exacerbated by sitting for prolonged periods**, unlike **lumbar spinal stenosis** which typically causes **bilateral** **symptoms** **exacerbated by standing or walking**.

Question 34

Describe the management of LSS [3]

Answer 34

**Conservative management:** - NSAIDS; paracetamol; opoids - Physio - Epidural injections - temporary pain relief **Decompression surgery**: removing bone or ligament tissue and relieving nerves **Spinal fusion**: This procedure stabilises the spine by fusing two or more vertebrae together using grafts or hardware.

Question 35

Describe the specific presentations for Osteosarcoma; Ewing’s sarcoma; Leiomyosarcoma [3]

Answer 35

**Osteosarcoma**: - Commonly presents with **localised bone pain** that **worsens** at **night** or with **activity**; occasionally accompanied by **swelling around the affected area** **Ewing’s sarcoma:** - Besides pain and **swelling, systemic symptoms such as fever, malaise, and weight loss** are often present due to the aggressive nature of this tumour **Leiomyosarcoma**: - Depending on its location, can cause a variety of symptoms. **Uterine** **leiomyosarcoma** may present with **abnormal uterine bleeding** while gastrointestinal leiomyosarcomas can cause **abdominal pain or gastrointestinal bleeding.**

Question 36

Describe the initial assessment used in diagnosis of a sarcoma [3]

Answer 36

**MRI** is the preferred modality due to its superior soft tissue contrast and multiplanar capability. **Employ PET-CT** for systemic staging to detect metastasis. **Perform a biopsy, either core needle or incisional**, for histopathological diagnosis. Avoid fine needle aspiration due to its limited diagnostic utility in sarcomas.

Question 37

The most common location for sarcoma to metastasise to is the **[]**.

Answer 37

The most common location for sarcoma to metastasise to is the **lungs**.

Question 38

What are the most common sites affected by osteosarcoma? [2] Why? [1]

Answer 38

**Distal femur and proximal tibia** - These locations are near the knee joint, where the **bone is growing rapidly**

Question 39

Which of the urethral sphincters is under voluntary control and what is its innervation? [1]

Answer 39

**External urethral sphincter** is under voluntary control through the **pudendal nerve (S2-S4).**

Question 40

What are the treatment options for spinal cord compression? [3]

Answer 40

Corticosteroids, surgery and radiotherapy.

Question 41

What nerve roots are affected in saddle anaesthesia? [1]

Answer 41

Saddle anaesthesia is a loss of sensation of the perineal area. This is due to cauda equina syndrome, where **L2-L5 nerve roots** coming off the spinal cord (cauda equina) are compressed. This is also an emergency.

Question 42

What is the most common non-haematological malignancy in children?

Answer 42

Osteosarcoma

Question 43

What are the management options in Ewing's sarcoma? [3]

Answer 43

* Referral to a **specialist centre** * **Neo-adjuvant chemotherapy**: vincristine, ifosfamide, doxorubicin and etoposide (**VIDE**) is a common combination * **Surgery**: may involve limb sparing surgery with a bone graft and reconstruction or a partial/complete amputation * **Adjuvant chemotherapy or radiotherapy**

Question 44

Which form of cancer typically shows a **sunburst appearance on x-ray of a bone**? [1]

Answer 44

**Osteosarcoma**

Question 45

Which form of cancer typically shows a **moth-eaten pattern of bone destruction**? [1]

Answer 45

**Chondrosarcoma**

Question 46

Describe the appearance of the following types of cancers on x-ray: 1. Ewing's sarcoma 2. Giant cell tumour 3. Osteosarcoma

Answer 46

1. Ewing's sarcoma: **onion skin** 2. Giant cell tumour: **soap bubble** 3. Osteosarcoma: **sunburst** ## Footnote Bite into a raw onion = ew thus, onion skin = ewings

Question 47

Giant cell tumours: - what x-ray changes? [1] - Which population? [1]

Answer 47

Bubble wrap / soap bubble signs 20-40 yr olds

Question 48

Osteosarcoma: - xray signs? [1] - Link with which other cancer? [1] - Population? [1]

Answer 48

* Sunburst * Retinoblastoma link * Children and adolescents