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4th year passmedicine by topic > Orthopaedics - Spine > Flashcards

Orthopaedics - Spine Flashcards

1
Q

Symmptoms of lesion in Dorsal column lesion

A

Loss vibration and proprioception

Tabes dorsalis, SACD

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2
Q

Symmptoms of lesion in Spinothalamic tract lesion

A

Loss of pain, sensation and temperature

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3
Q

Symmptoms of lesion in Central cord lesion

A

Flaccid paralysis of the upper limbs

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4
Q

Infarction spinal cord results in what signs

A

Dorsal column signs (loss of proprioception and fine discrimination

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5
Q

Cord compression results in what signs

A

UMN signs
Malignancy
Haematoma
Fracture

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6
Q

Osteomyelitis is normally progressive

A

True

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7
Q

Osteomyelitis - which parts of the spine are affected with which patient groups?

A

Staph aureus in IVDU, normally cervical region affected

Thoracic region affected in TB

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8
Q

Osteomyelitis - what type of infections in immunocompromised?

A

Fungal

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9
Q

What is Brown-sequard syndrome & what signs do you get?

A

Hemisection of the spinal cord
Ipsilateral paralysis
Ipsilateral loss of proprioception and fine discrimination
Contralateral loss of pain and temperature

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10
Q

Describe the dermatomal distribution of C2 to C4

A

The C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle. C4 covers the area just below the clavicle.

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11
Q

Describe the dermatomal distribution of C5 to T1

A

Situated in the arms. C5 covers the lateral arm at and above the elbow. C6 covers the forearm and the radial (thumb) side of the hand. C7 is the middle finger, C8 is the medial aspect of the hand, and T1 covers the medial side of the forearm.

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12
Q

Describe the dermatomal distribution of T2 to T12

A

The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is situated at the umbilicus. T12 ends just above the hip girdle.

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13
Q

Describe the dermatomal distribution of L1 to L5

A

The cutaneous dermatome representing the hip girdle and groin area is innervated by L1 spinal cord. L2 and 3 cover the front part of the thighs. L4 and L5 cover medial and lateral aspects of the lower leg.

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14
Q

Describe the dermatomal distribution of S1 to S5

A

S1 covers the heel and the middle back of the leg. S2 covers the back of the thighs. S3 cover the medial side of the buttocks and S4-5 covers the perineal region. S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.

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15
Q

Describe myotomes in the upper limb

A 
Elbow flexors/Biceps	C5
Wrist extensors	C6
Elbow extensors/Triceps	C7
Long finger flexors	C8
Small finger abductors	T1
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16
Q

Describe myotomes in the lower limb

A 
Hip flexors (psoas)	L1 and L2
Knee extensors (quadriceps)	L3
Ankle dorsiflexors (tibialis anterior)	L4 and L5
Toe extensors (hallucis longus)	L 5
Ankle plantar flexors (gastrocnemius)	S1
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17
Q

The anal sphincter is innervated by

A

S2,3,4

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18
Q

What does Froment’s sign assess

A

ulnar nerve palsy

Adductor pollicis muscle function tested

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19
Q

Describe Froment’s sign?

A

Hold a piece of paper between their thumb and index finger. The object is then pulled away. If ulnar nerve palsy, unable to hold the paper and will flex the flexor pollicis longus to compensate (flexion of thumb at interphalangeal joint).

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20
Q

Describe Phalen’s test

A

Assess carpal tunnel syndrome

Hold wrist in maximum flexion and the test is positive if there is numbness in the median nerve distribution.

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21
Q

Describe Tinel’s sign

A

Assess for carpal tunnel syndrome
Tap the median nerve at the wrist and the test is positive if there is tingling/electric-like sensations over the distribution of the median nerve.

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22
Q

Tine;s more sensitive than Phalens

A

false

Phalens most sensitive

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23
Q

Lower back pain (LBP) is one of the most common presentations seen in practice & majority of presentations will be of a non-specific muscular nature

A

true

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24
Q

Red flags for lower back pain

A 
age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever
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25
Q

Ankylosing spondylitis typical story

A

Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity

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26
Q 
In ankylosing spondylitis
Peripheral arthritis (?%, more common if female)
A

25%

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27
Q

Spinal stenosis acute/ gradual onset

A

gradual

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28
Q

spinal stenosis symptoms

A

Unilateral or bilateral LEG pain (with or without back pain)
Numbness, and weakness which is worse on walking. Resolves when sits down.
Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down

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29
Q

Peripheral arterial disease sx

A

Pain on walking, relieved by rest

Absent or weak foot pulses and other signs of limb ischaemia

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30
Q

Peripheral arterial disease PMH

A

smoking and other vascular diseases

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31
Q

Facet join pain is always acute

A

May be acute or chronic

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32
Q

Facet join pain examination findings

A

On examination there may be pain over the facets. The pain is typically worse on extension of the back

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33
Q

Facet join pain sx

A

Pain worse in the morning and on standing

34
Q

Spinal stenosis clinical exam often normal

A

true

35
Q

confirm diagnosis ix spinal stenosis

A

MRI

36
Q

non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) always doe a lumbar spine x ray

A

false

lumbar spine x-ray should not be offered

37
Q

non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) when is MRI indicated

A

should only be offered to patients with non-specific back pain ‘only if the result is likely to change management’ and to patients where malignancy, infection, fracture, cauda equina or ankylosing spondylitis is suspected
it is the most useful imaging modality as no other imaging can see neurological / soft tissue structures

38
Q

non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) - advice

A

try to encourage self-management

stay physically active and exercise

39
Q

non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) - analgesia

A

NSAIDS are now recommended first-line for patients with back pain. This follows studies that show paracetamol monotherapy is relatively ineffective for back pain
proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given NSAIDs
NICE guidelines on neuropathic pain should be followed for patients with sciatica

40
Q

non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) - other treatments

A

exercise programme: ‘Consider a group exercise programme (biomechanical, aerobic, mindbody or a combination of approaches) within the NHS for people ‘
manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) ‘but only as part of a treatment package including exercise, with or without psychological therapy.’
radiofrequency denervation
epidural injections of local anaesthetic and steroid for acute and severe sciatica

41
Q

A prolapsed lumbar disc usually produces what type of pain picture

A

clear dermatomal leg pain associated with neurological deficits
leg pain usually worse than back
pain often worse when sitting

42
Q

Features of L3 nerve root compression

A

Sensory loss over anterior THIGH
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

43
Q

Features of L4 nerve root compression

A

Sensory loss anterior aspect of KNEE
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

44
Q

Features of L5 nerve root compression

A

Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test

45
Q

Features of S1 nerve root compression

A

Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test

46
Q

mx prolapsed disc

A

similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises
if symptoms persist 9e.g. after 4-6 weeks) then referral for consideration of MRI is appropriate

47
Q

What is lumbar spinal stenosis

A

Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk prolapse or other similar degenerative changes.

48
Q

lumbar spinal stenosis presentation

A

combination of back pain, neuropathic pain and symptoms mimicking claudication.

49
Q

lumbar spinal stenosis - how to differentiate from true claudication

A

One of the main features that may help to differentiate it from true claudication in the history is the positional element to the pain. Sitting is better than standing and patients may find it easier to walk uphill rather than downhill. The neurogenic claudication type history makes lumbar spinal stenosis a likely underlying diagnosis, the absence of such symptoms makes it far less likely.

50
Q

Pathology of lumbar spinal stenosis

A

Degenerative disease is the commonest underlying cause.

Degeneration is believed to begin in the intervertebral disk where biochemical changes such as cell death and loss of proteoglycan and water content lead to progressive disk bulging and collapse. This process leads to an increased stress transfer to the posterior facet joints, which accelerates cartilaginous degeneration, hypertrophy, and osteophyte formation; this is associated with thickening and distortion of the ligamentum flavum. The combination of the ventral disk bulging, osteophyte formation at the dorsal facet, and ligamentum flavum hyptertrophy combine to circumferentially narrow the spinal canal and the space available for the neural elements. The compression of the nerve roots of the cauda equina leads to the characteristic clinical signs and symptoms of lumbar spinal stenosis.

51
Q

Diagnosis of lumbar spinal stenosis

A

MRI scanning is the best modality for demonstrating the canal narrowing.

52
Q

Treatment of lumbar spinal stenosis

A

Laminectomy

53
Q

What is cauda equina syndrome

A

rare but serious condition in which the lumbosacral nerve roots that extend below the spinal cord are compressed.

54
Q

It is important to consider CES in any patient who presents with new/worsening lower back pain.

A

true

55
Q

CES Late diagnosis may lead to

A

permanent nerve damage resulting in long term leg weakness and urinary/bowel incontinence.

56
Q

Causes CES

A 
the most common cause is a central disc prolapse
this typically occurs at L4/5 or L5/S1
other causes include:
tumours: primary or metastatic
infection: abscess, discitis
trauma
haematoma
57
Q

It is important to recognise that CES may present in a variety of ways and there is no one symptom/sign that can diagnose nor exclude CES

A

true

58
Q

Ix & Mx CES

A

urgent MRI

Surgical decompression

59
Q

Possible features CES

A 
low back pain
bilateral sciatica
reduced sensation/pins-and-needles in the perianal area
decreased anal tone
urinary dysfunction
60
Q

bilateral sciatica is present in ?% of CES

A

50%

61
Q

decreased anal toneis highly specific for CES

A

it is good practice to check anal tone in patients with new-onset back pain
however, studies show this has poor sensitivity and specificity for CES

62
Q

Describe urinary dysfunction in CES

A

e.g. incontinence, reduced awareness of bladder filling, loss of urge to void
incontinence is a late sign that may indicate irreversible damage

63
Q

Cervical spondylosis is an extremely common condition that results from

A

osteoarthritis.

64
Q

Cervical spondylosis presentation

A

It most commonly presents as neck pain although referred pain may mimic headaches etc.

65
Q

Cervical spondylosis complications

A

radiculopathy and myelopathy.

66
Q

what is osteoporosis

A

condition where bones gradually decrease in bone mineral density, thus increasing the likelihood of fragility fractures. Fragility fractures are fractures that occur as a result of mechanical forces which would not usually lead to a fracture

67
Q

one of the most common sites of osteoporotic fractures is

A

vertebra

68
Q

Osteoporotic vertebral fracture presentation

A

Asymptomatic: an osteoporotic vertebral fracture may be diagnosed through an incidental finding on X-ray
Acute back pain
Breathing difficulties:
Gastrointestinal problems

69
Q

Osteoporotic vertebral fracture - why do you get breathing difficulties & gi ISSUES

A

changes in the shape and length of vertebrae lead to the compression of organs such as the lungs, heart and intestine
Gastrointestinal problems: due to compression of abdominal organs

70
Q

Osteoporotic vertebral fracture are mostly caused by trauma

A

false

Only a minority of patients will have a history of fall/trauma

71
Q

Osteoporotic vertebral fracture signs

A

Loss of height: vertebral osteoporotic fractures of lead to compression of the spinal vertebrae hence a reduction in overall length of the spine and thus the patient becomes shorter
Kyphosis (curvature of the spine)
Localised tenderness on palpation of spinous processes at the fracture site

72
Q

Osteoporotic vertebral fracture first ix ( what does this show)

A

X-ray of the spine: This should be the first investigation ordered and may show wedging of the vertebra due to compression of the bone. An X-ray of the spine may also show old fractures (which can have a sclerotic appearance)

73
Q

Osteoporotic vertebral fracture other ix

A

CT spine: gives a more detailed view of the bone structure, therefore can visualise the extent/features of the fracture more clearly
MRI spine: Useful for differentiating osteoporotic fractures from those caused by another pathology e.g. a tumour

74
Q

Osteoporotic vertebral fracture - assessing risk of second event

A

risk factors are taken into account and a dual-energy X-ray absorptiometry (DEXA) scan should be considered. DEXA scans essentially assess bone mineral density. According to NICE, the FRAX tool or QFracture tool can be used to estimate the 10-year risk of a fracture. These tools each require the clinician to input patient information into a form and this information is used by the programme to calculate the risk.

75
Q

Osteoporosis is far more common in females than in males.

A

true
The male-to-female ratio is 1:6.
25% of women will have developed osteoporosis by the age of 80 .

76
Q

Risk factors for osteoporotic fractures

A

Advancing age is a major risk factor osteoporotic fractures:
Previous history of a fragility fracture
Frequent or prolonged use of glucocorticoids
History of falls
Family history of hip fracture

Low BMI (< 18.5)
Tobacco smoking
High alcohol intake: > 14 units/week for women, > 21 units/week for men
77
Q

When should people be consider for fracture assessment?

A

Women ≥ 65 years old and men ≥ 75 years old should be considered for fracture risk assessment.

78
Q

reduced oestrogen levels is a risk factor for osteoporosis.

A

true

79
Q

causes of secondary osteoporosis

A

Cushing’s disease, hyperthyroidism, chronic renal disease

80
Q

High BMI is risk factor for osteoporosis

A

false

low <18.5

4th year passmedicine by topic (96 decks)

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