Session 7 clinical conditions Flashcards
What is cervical spondylosis
Chronic degenerative osteoarthritis
affecting intervertebral joints in cervical spine
Primary pathology of cervical spondylosis
Age related disc degeneration, marginal osteophytosis, facet joint osteoarthritis
What is the consequence of resultant narrowing of intervertebral foramina in cervical spondylosis
Puts pressure on spinal nerves leading to radiculopathy (dermatomal sensory symptoms and myotomal motor weakness)
Consequence of narrowing of spinal canal in spondylosis
Myelopathy (pressure on spinal cord)
Less common
Global muscle weakness, gait dysfunction, loss of balance, incontinence
What is Jefferson’s fracture
Fracture of anterior and posterior arches of atlas C1
Axial loading
Typically pain but no neurological signs
Occasional complication of Jeffersons fracture
damage to arteries at base of skull
secondary neurological sequelae (ataxia, stroke, Horner’s syndrome)
What is Hangman’s fracture
Axis C2 is fractured through pars interarticularis (between superior and inferior articular processes)
Forcible hyperextension of neck
Unstable- needs treatment
Cause of fractures of the odontoid process and detection
Flexion or extension
open mouth X ray or CT
What is whiplash
forceful hyperextension/hyperflexion injury of cervical spine
tearing of cervical muscles and ligaments
Consequence of whiplash
secondary oedema
haemorrhage
inflammation
Spasm
Sometimes injury to cervical cord
What is myofascial pain syndrome
secondary issue in response to a disc or facet joint injury
Such as whiplash
Protective mechanism against spinal cord injury in whiplash
vertebral foramen is large relative to diameter of cord in cervical region
How can sequestration be resolved
extruded segment of nucleus pulposus is resorbed in spinal canal
Problem with cervical nerves
little space for exiting nerves
Symptoms in C5/C6 left prolapse
parenthesia in radial border of left forearm, thumb and index finger on left
Weakness in left elbow flexion, supination and wrist extension
Pain in neck radiating down left arm over biceps and to skin supplied by C6
What is cervical myelopathy
Spinal cord dysfunction due to compression of cord by narrowing of vertebral canal
Commonest cause of cervical myelopathy
cervical spondylosis
e.g. ligamentum flavum hypertrophy or buckling, facet joint hypertrophy, disc protrusion and osteophyte formation
Reduction in canal diameter resulting in cord compression
Other causes of cervical myelopathy
congenital stenosis of spinal canal Cervical disc herniation Spondylolisthesis trauma tumour RA
When do myelopathic symptoms start
<12-14mm spinal canal
Classic cervical myelopathy presentation
loss of balance with poor coordination decreased dexterity weakness numbness or paralysis pain or not rapid deterioration of gait and hand function in elderly
Classic upper and lower cervical lesions presentation
Upper- loss of manual dexterity, Dysdiadochonkonesia (impaired ability to perform rapid alternating movements)
Lower- spasticity, loss of proprioception in legs, legs feel heavy, reduced exercise tolerance, gait disturbance, multiple falls
What do hoffmans and Babinski tests test for
Exaggerated response to stimulation (Hoffmans or Babinski sign)
Hoffmans test
flick fingernail of middle phalanx
if the index finger and thumb move- patient has a positive sign
Babinski sign
lateral side of sole of foot stroked with a blunt instrument from heel to toe
Normal = flexor response (2-3+)
Babinski sign = hallux dorsiflexes and toes fan out
What is Lhermitte’s phenomenon
sensation of intermittent electric shocks in the limbs
Exacerbated by neck flexion
Classically associated with cervical myelopathy
Symptoms may progress to sphincter dysfunction and quadriplegia if surgical decompression is not performed
Symptoms of myelopathy of cervical spine at C5
neck pain
weakness of shoulder abduction and external rotation
weakness of all myotomes distally
paraesthesia from the shoulder distally
Commonest causes of thoracic cord compression
vertebral fractures with bony fragments in spinal canal or tumours in spinal canal
Common sites for metastasis
1st = pelvis 2nd = spine
Most common cancers that arise from solid organs and spread to bone are
breast, lung, thyroid, kidney and prostate
Metastasis in T12 vertebra would compress
L4-5 segments of sinal cord
Symptoms of spinal cord compression from a metastasis at T10
pain in thoracic spine, spastic paralysis of all muscles in legs, parawsthesia in dermatomes distal to site of cord compression, loss of sphincter control
T5 metastasis presentation
weakness of intercostal muscles from 5th intercostal space, reduced chest expansion on inspiration diaphragmatic breathing
Paraethesia from below nipples distally
Weakness of leg muscles and loss of sphincter control
3 routes for pathogens reaching bones and tissues of spine
Haematogenous (most common)
Direct inoculation during invasive spinal procedure
Spread from adjacent soft tissue infection
Infection of intervertebral disc is called
spondylodiscitis or discitis
Spondylodiscitis is most common in
immunocompromised patients (diabetes, HIV, patients on steroids)
Where are organisms initially deposited
Vertebral body, via segmental artery, leading to bony ischaemia and infarction
Necrosis allows direct spread into disc space epidural space and adjacent vertebral bodies
Spread of infection into spinal canal can lead to neurological damage via
Septic thrombosis leading to ischaemia
Compression of neural elements by abcess/inflammatory tissue
Direct invasion of neural elements by inflammatory tissue
Mechanical collapse of bone leading to instability, particularly in chronic infections
Most common organisms for spread of infection to spinal canal
Staph aureus, gram neg bacillus such as E coli,
Following surgery = coagulase negative staph
Drug users IV = pseudomonas, candida
