Section 1

Question 1

Useful Red Flags

Answer 1

No consensus on which are most useful to identify serious spinal pathology

RF used in COMBINATION have promise, but used in ISOLATION are not informative

Question 2

Decision Tool for Early Identification of Serious Spinal Pathology 3 steps:

Answer 2

1. Determine level of concern
2. Decide on clinical action
3. Consider the pathway for emergency/urgent referral

Question 3

Cauda Equina Syndrome CES

Risk Factors/precursors:

Answer 3

Usually a result of disc prolapse, any space occupying lesion, unilateral or bilateral radicular pain, dermatomal reduced sensation, myotomal weakness

Question 4

When to suspect Cauda Equina Syndrome CES

Answer 4

progression from precursors: prolapse, space occupying lesion, uni/bi radicular pain, dermatomal reduced sensation, myotomal weakness WITH any changes in bladder/bowel function or saddle sensory disturbance

Question 5

What to do if CES is suspected?

Answer 5

Perform FULL neurological assessment to establish dermatome sensory loss, myotome weakness, or reflex changes.

Emergency MRI and surgical opinion, positive findings likely accompanied by ultrasound of bladder

Question 6

MC cause Cauda Equina Syndrome CES

Answer 6

large central disc herniation at L4-5 or L5-S1

Under 50 yo or obese = higher risk

Question 7

Presentations that increase probability of acute threatened CES:

Answer 7

back pain WITH:
new saddle anesthesia or bowel disturbance

age less than 50

unilateral onset progressing to bilateral leg P

alternating leg P

new motor weakness

bowel:
incomplete emptying, urinary hesitancy, incontinence, nocturia, urinary tract infections

Question 8

Gold standard investigation to confirm CES

Answer 8

urgent MRI

CT when MRI contraindicated

Question 9

Safety net:

Answer 9

Discuss/document clear strategy to follow if symptoms deteriorate to ensure the pt knows they need to act immediately if things get worse

Question 10

Makes up the largest number of serious pathologies in the spine

Answer 10

Spinal fracture

Question 11

MC spinal fracture levels

Answer 11

T8-L4

Question 12

Spinal Fracture Prevalence in Women

Answer 12

12% of women 50-70yrs

20% over 70yrs

as much as 70% undiagnosed

Question 13

Common spinal fracture presentation:

Answer 13

sudden onset of pain

MC in thoracic region

following low-impact trauma/slip/fall

lifting in the flexed position

severe P local to area of fx

weight-bearing & active movements are restricted and painful

may require strong analgesia

increased prominence of SP, increased kyphosis

tender to percussion

Question 14

Spinal fracture DDX

Answer 14

metastatic spinal disease

multiple myeloma

Question 15

First-line investigations for spinal fracture

Answer 15

x-ray first-line choice
MRI choice for differentiating osteoporotic fx from metastatic disease and myeloma

CT can be helpful to evaluate complex fx or retropulsed fragments, or used where MRI contraindicated

Question 16

2nd most common serious pathology to affect spine

Answer 16

Spinal malignancy

Question 17

5 MC cancers to metastasize to the spine:

Answer 17

breast
prostate
lung
kidney
thyroid

(30% of these will metastasize)

Question 18

When can metastatic bone disease MBD occur with breast cancer?

Answer 18

can occur at any time
50% within 5 years of dx
50% developing 10yrs and later

Question 19

Metastatic spinal cord compression:

Answer 19

can be a consequence of metastatic bone disease MBD when a pathological vertebral body collapses or direct tumor growth causes compression of spinal cord

Question 20

MC Metastasis locations in the spine:

Answer 20

thoracic spine 70%
lumbar 20%
cervical 10%

Question 21

Spinal infection MC Cause

Answer 21

Post-procedural discitis 30% of all ases

Question 22

Discitis MC spinal areas affected

Answer 22

lumbar spine 58%
thoracic spine 30%
cervical spine 11%

Question 23

MC presenting symptom of spinal infection

Answer 23

back pain

can progress to neurological symptoms

Question 24

Comorbidities that increase risk for spinal infection

Answer 24

suppressed immune system:

DM, HIV, LT steroid use, smoking

Question 25

Social and environmental factors increasing risk for spinal infection

Answer 25

IV drug use
obesity
birth in TB endemic country
fam hx of TB
poor living conditions
spinal surgery (esp multiple revision lumbar spine)

Question 26

CLASSIC TRIAD clinical features for spinal infection

Answer 26

back pain
fever
neurological dysfunction

(only 50% report fever)