Serious Spinal Pathology

Question 1

Decision tool for early identification of spinal pathology

Answer 1

• Determine your level of concern
• Decide the clinical action based on level of concern
• Consider the pathway for emergency/urgent referral

Question 2

Examples of serious spinal pathologies

Answer 2

• Cauda Equina Syndrome (CES)
• Spinal fracture
• Malignancy
• Spinal infection

Question 3

Describe cauda equina syndrome

Answer 3

• Compression of the 20 nerve roots that originate from the conus medullar is at the base of the spinal cord
• Timely diagnosis is essential to avoid life changing outcomes such as ongoing bladder, bowel, & sexual dysfunction, along with psychological consequences

Question 4

Risk factors of cauda equina syndrome

Answer 4

• Disc prolapse, space occupying lesion
• Symptoms: uni/bilateral radicular pain, dermatomal reduced sensation, myotomal weakness with progression to changes in bowel/bladder & saddle anesthesia

Question 5

Clinical picture of cauda equina syndrome

Answer 5

• Conduct the full neurological assessment
• Send for imaging (MRI) vs “safety netting”

Question 6

Cauda equina syndrome warning signs (any combination seek help immediately)

Answer 6

• Loss of feeling/pins & needles b/w inner thighs or genitals
• Numbness in or around your back passage or butt
• Altered feeling when using toilet paper to wipe
• Increasing difficulty when try to urinate
• Increasing difficulty when try to stop or control flow of urine
• Lass of sensation when you pass urine
• Leaking urine or recent need to use pads
• Not knowing when bladder is full or empty
• Inability to stop bowel movement or leaking
• Loss of sensation when pass a bowel motion
• Change in ability to achieve an erection or ejaculate
• Loss of sensation in genitals during sexual intercourse

Question 7

Describe a spinal fracture

Answer 7

• Largest # of serious spinal pathology
• Low impact or non traumatic fractures are the most common serious pathology in the spine with vertebral fractures being the most common osteoporotic fracture
• Osteoporotic fx have similar distribution as metastases with 70% in thoracic region, 20% in lumbar, and 10% in cervical
• Most spinal fractures occur b/w T8 and L4 levels

Question 8

Risk factors for insufficiency spinal fractures (younger pts)

Answer 8

• Excessive alcohol consumption (>3 units per day)
• Vitamin D deficiency
• Long term corticosteroid use (>5 or 7.5 mg/day over a 3 mo period)
• RA, DM, smoking (>20 cigarettes per day = one pack)
• Dietary restriction, eating disorders, & absorption problems from the gut
• Establish the presence or absence of these risk factors with detailed history taking

Question 9

Clinical picture for spinal fracture

Answer 9

• Sudden onset of pain in the thoracolumbar region after a low impact trauma (slip/fall)
• Severe pain, localized to area of fx, needs strong analgesics
• Increased prominence of spinous process at the affected level & increased kyphosis
• Tender to percussion at the affected level

Question 10

Differential diagnosis of spinal fractures

Answer 10

• Metastatic spinal disease
• Multiple myeloma

Question 11

Describe spinal malignancy

Answer 11

• Bone is common site for metastases known as metastatic bone disease (MBD) & the spine is one of the earliest sites impacted: Breast, Prostate, Lungs, Kidneys, & Thyroid (metastases from these sites to the spine)
• Metastatic spinal cord compression can occur when there is pathological vertebral body collapse or where direct tumor growth causes compression of the spinal cord leading to irreversible neurological damage
• Primary tumors that are at high risk of metastasizing are those that were large at diagnosis, diagnosed at late stage, or had lymph node involvement with radical Tx including surgery, chemotherapy, &/or radiotherapy

Question 12

Early warning signs of metastatic spinal cord compression (MSCC)

Answer 12

• REDFLAGS
• Referred back pain is multi-segmental or band like
• Escalating pain which is poorly responsive to treatment
• Different character or site to previous Sx
• Funny feeling, odd sensations or heavy legs
• Lying flat increases back pain
• Agonizing pain causing anguish & despair
• Gait disturbance, unsteadiness, especially on stairs
• Sleep grossly disturbed due to pain being worse at night

Question 13

Key red flags for metastatic spinal cord compression (MSCC)

Answer 13

• Past medical history of cancer
• Early diagnosis is essential as the prognosis is severely impaired once paralysis occurs
• A combination of red flags increases suspicion: the more red flags the higher the risk

Question 14

Describe spinal infection

Answer 14

• Spinal infection is an infectious disease that affects the spinal structures including the vertebrae, intervertebral discs, & adjacent paraspinal tissues
• Spinal infection represents 2-7% of all MSK infections
• Discitis mostly affects the lumbar spine (58%), followed by the thoracic spine (30%), & cervical spine (11%)
• TB lesions mainly affect the thoracic spine & often at more than 2 levels

Question 15

Differences between spinal malignancy and spinal infection

Answer 15

• Unlike malignancy, where symptoms wax & mane, spinal infection has a more linear progression, with back pain being the most common presenting symptom, which can progress to neurological symptoms
• Spinal infection can progress to paralysis, instability of the spine, and/or fatality

Question 16

Clinical picture of spinal infection

Answer 16

• Comorbidities that suppress the immune system: DM, HIV, long term steroid use, smoking
• Social & environmental factors: TB and TB endemic country, IV drug use, obesity, homelessness, imprisionment, rural environment
• Spinal surgery is a key risk factor for spinal infection in particular multiple revision surgery of the lumbar spine with an added increased risk for obese people

Question 17

Classic triad of clinical features for spinal infection

Answer 17

• Back pain
• Fever
• Neurological dysfunction
• Absence of fever cannot rule out spinal infection