Orthopaedics - Spine Flashcards
Symmptoms of lesion in Dorsal column lesion
Loss vibration and proprioception
Tabes dorsalis, SACD
Symmptoms of lesion in Spinothalamic tract lesion
Loss of pain, sensation and temperature
Symmptoms of lesion in Central cord lesion
Flaccid paralysis of the upper limbs
Infarction spinal cord results in what signs
Dorsal column signs (loss of proprioception and fine discrimination
Cord compression results in what signs
UMN signs
Malignancy
Haematoma
Fracture
Osteomyelitis is normally progressive
True
Osteomyelitis - which parts of the spine are affected with which patient groups?
Staph aureus in IVDU, normally cervical region affected
Thoracic region affected in TB
Osteomyelitis - what type of infections in immunocompromised?
Fungal
What is Brown-sequard syndrome & what signs do you get?
Hemisection of the spinal cord
Ipsilateral paralysis
Ipsilateral loss of proprioception and fine discrimination
Contralateral loss of pain and temperature
Describe the dermatomal distribution of C2 to C4
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.
Describe the dermatomal distribution of C5 to T1
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.
Describe the dermatomal distribution of T2 to T12
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.
Describe the dermatomal distribution of L1 to L5
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.
Describe the dermatomal distribution of S1 to S5
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.
Describe myotomes in the upper limb
Elbow flexors/Biceps C5 Wrist extensors C6 Elbow extensors/Triceps C7 Long finger flexors C8 Small finger abductors T1
Describe myotomes in the lower limb
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
The anal sphincter is innervated by
S2,3,4
What does Froment’s sign assess
ulnar nerve palsy
Adductor pollicis muscle function tested
Describe Froment’s sign?
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).
Describe Phalen’s test
Assess carpal tunnel syndrome
Hold wrist in maximum flexion and the test is positive if there is numbness in the median nerve distribution.
Describe Tinel’s sign
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.
Tine;s more sensitive than Phalens
false
Phalens most sensitive
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
true
Red flags for lower back pain
age < 20 years or > 50 years history of previous malignancy night pain history of trauma systemically unwell e.g. weight loss, fever
Ankylosing spondylitis typical story
Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
In ankylosing spondylitis Peripheral arthritis (?%, more common if female)
25%
Spinal stenosis acute/ gradual onset
gradual
spinal stenosis symptoms
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
Peripheral arterial disease sx
Pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Peripheral arterial disease PMH
smoking and other vascular diseases
Facet join pain is always acute
May be acute or chronic
Facet join pain examination findings
On examination there may be pain over the facets. The pain is typically worse on extension of the back
Facet join pain sx
Pain worse in the morning and on standing
Spinal stenosis clinical exam often normal
true
confirm diagnosis ix spinal stenosis
MRI
non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) always doe a lumbar spine x ray
false
lumbar spine x-ray should not be offered
non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) when is MRI indicated
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
non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) - advice
try to encourage self-management
stay physically active and exercise
non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) - analgesia
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
non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) - other treatments
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
A prolapsed lumbar disc usually produces what type of pain picture
clear dermatomal leg pain associated with neurological deficits
leg pain usually worse than back
pain often worse when sitting
Features of L3 nerve root compression
Sensory loss over anterior THIGH
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
Features of L4 nerve root compression
Sensory loss anterior aspect of KNEE
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
Features of L5 nerve root compression
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
Features of S1 nerve root compression
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
mx prolapsed disc
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
What is lumbar spinal stenosis
Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk prolapse or other similar degenerative changes.
lumbar spinal stenosis presentation
combination of back pain, neuropathic pain and symptoms mimicking claudication.
lumbar spinal stenosis - how to differentiate from true claudication
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.
Pathology of lumbar spinal stenosis
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.
Diagnosis of lumbar spinal stenosis
MRI scanning is the best modality for demonstrating the canal narrowing.
Treatment of lumbar spinal stenosis
Laminectomy
What is cauda equina syndrome
rare but serious condition in which the lumbosacral nerve roots that extend below the spinal cord are compressed.
It is important to consider CES in any patient who presents with new/worsening lower back pain.
true
CES Late diagnosis may lead to
permanent nerve damage resulting in long term leg weakness and urinary/bowel incontinence.
Causes CES
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
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
true
Ix & Mx CES
urgent MRI
Surgical decompression
Possible features CES
low back pain bilateral sciatica reduced sensation/pins-and-needles in the perianal area decreased anal tone urinary dysfunction
bilateral sciatica is present in ?% of CES
50%
decreased anal toneis highly specific for CES
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
Describe urinary dysfunction in CES
e.g. incontinence, reduced awareness of bladder filling, loss of urge to void
incontinence is a late sign that may indicate irreversible damage
Cervical spondylosis is an extremely common condition that results from
osteoarthritis.
Cervical spondylosis presentation
It most commonly presents as neck pain although referred pain may mimic headaches etc.
Cervical spondylosis complications
radiculopathy and myelopathy.
what is osteoporosis
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
one of the most common sites of osteoporotic fractures is
vertebra
Osteoporotic vertebral fracture presentation
Asymptomatic: an osteoporotic vertebral fracture may be diagnosed through an incidental finding on X-ray
Acute back pain
Breathing difficulties:
Gastrointestinal problems
Osteoporotic vertebral fracture - why do you get breathing difficulties & gi ISSUES
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
Osteoporotic vertebral fracture are mostly caused by trauma
false
Only a minority of patients will have a history of fall/trauma
Osteoporotic vertebral fracture signs
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
Osteoporotic vertebral fracture first ix ( what does this show)
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)
Osteoporotic vertebral fracture other ix
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
Osteoporotic vertebral fracture - assessing risk of second event
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.
Osteoporosis is far more common in females than in males.
true
The male-to-female ratio is 1:6.
25% of women will have developed osteoporosis by the age of 80 .
Risk factors for osteoporotic fractures
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
When should people be consider for fracture assessment?
Women ≥ 65 years old and men ≥ 75 years old should be considered for fracture risk assessment.
reduced oestrogen levels is a risk factor for osteoporosis.
true
causes of secondary osteoporosis
Cushing’s disease, hyperthyroidism, chronic renal disease
High BMI is risk factor for osteoporosis
false
low <18.5
