spinal cord Flashcards
low back pain: how common is this complaint and causes
-84% of adults at some point
-lumbar strain
-degenerative ds- arthritis -> bony spurs: pain + inflammation
-discogenic pain (herniated disc)
-facet joint pain: arthritis
-spondylosis
-anterolishtesis- bone slips forward
-spinal stenosis
lumbar strain: what sx, workup, and tx
-Non-specific low back pain
-Not related to underlying serious disorder
-Often self resolves in 3 weeks
workup:
-Imaging NOT recommended if back pain unless lasting >4 weeks or if there is presence of red flags
-Labs not required
management: Non-pharm management is 1st line
-HEAT
-NO BED REST!- muscles get weaker -> more pain
-ACTIVITY MODIFICATION
-pharm tx: NSAIDs short-term
What is NOT needed in lumbar strain?
-Early PT
-Injections
-Advanced imaging early in the course of lumbar strain
-Opioids
reassure pt
spinal stenosis (neuroclaudication): definition, causes
Definition: Narrowing of canal causes compression on nerve roots
-MC >50yo
- neurogenic claudication sx
Causes:
-Congenital narrowing
-Osteoarthritis
-CENTRAL Disc herniation*
-Trauma
-Vertebral body fractures
-Fragility in osteoporosis
-Degenerative changes
-Disc height loss
-Bone spur growth (osteophytes)
-Facet bone overgrowth
-Ligamentum flavum thickening
-Degenerative spondylolisthesis
spinal stenosis neuroclaudication: sx
-Symptoms ofneurogenic claudication!:
-Pain/cramping in one/both legs when standing or walking for long periods
-Back pain +/- radiation to butt or legs
-Numbness, weakness, or tinglingunilaterally or bilaterally
-can be asymmetrical
-Shopping cart sign:
-Worse with extension* (prolonged standing)- narrows the spinal canal
-Improved with flexion* (bending forward)
-Severe: Urinary incontinence, difficulty walking (Cauda Equina syndrome)
spinal stenosis neuroclaudication: Dx and tx
PE: Typically NORMAL
-MRI will show spinal stenosis and cause (spondylolisthesis, mass, etc)
TX:
- NSAIDs
- PT
- Weight loss
- bracing
- epidural injection of steroids
-Surgical tx: decompression laminectomy
diff dx of neuropathic and vascular claudication
-vascular depends on moving -> muscle
cauda equina and conus medullaris syndrome
-Spinal cord terminates at the conus medullaris between L1-L2
-The most distal bulbous part of the spinal cord is called the conus medullaris.
-Below this lies the nerves that make up the cauda equina
what is cauda equina syndrome
-Characteristic pattern of neuromuscular and urogenital symptoms resulting from the simultaneous compression of multiple lumbosacral nerve roots below the level of the conus medullaris.
-LMN lesion.
-Compression of the nerves may be IRREVERSIBLE thus it is a neurosurgical emergency!!
Stat imaging, medication, and surgery is needed!
- Bilateral leg pain and BLADDER AND BOWEL CHANGES**
causes of cauda equina syndrome
-Lumbar stenosis (multilevel)
-Spinal trauma including fractures
-Herniated nucleus pulposus (HNP) - 90% of lumbar disk herniations occur either at L4-L5 or L5-S1.
-Neoplasm: metastases, astrocytoma, neurofibroma, and meningioma
-20% of all spinal tumors affect this area
-Spinal infection/abscess: TB, HSV, meningitis, meningovascular syphilis, CMV, schistosomiasis
cauda equina presentation
-Low back pain & Sciatica (97%)
-Lower extremity weakness, paresthesia’s
-Severe neuropathic pain
-Saddle or perineum anesthesia (92%)
-Bladder dysfunction (92%)- retention FIRST -> overflow incontinence
-Bowel dysfunction (72%): late sign
-Sexual dysfunction (impotence in men)
-Areflexic paraplegia, atrophy – late signs
- usually BILATERAL LEG PAIN
- saddle anesthesia: numbness
cauda equina syndrome evaluation - risk factors and PE
Risk factors:
-Malignancy history
-Recent trauma
-IV drug use - abscess
-Anticoagulation - bleed
-Spinal instrumentation
PE:
-Motor or sensory deficits in the legs
-Usually bilateral leg pain*
-Can be unilateral or asymmetrical
-LMN signs in chronic cord compression: areflexia, hypotonia, atrophy
-Saddle anesthesia - where you sit on a horse -> numb
-↓ or absent rectal tone -> everyone gets a rectal exam
-Abdomen = large bladder (retention)
cauda equina syndrome imaging and management
-STAT MRI cord-compression series = gold standard!
-CT myelogram if unable to obtain MRI (metal implants)
-Consider post-void residual (>100cc generally neurologic)
Management: Neurosurgical emergency!!!
-Technically a clinical diagnosis -> STAT consultation… call the surgeon!!!
-(even before MRI if high suspicion)
-Decompression within 24 hrs window*
conus medullaris syndrome (dont memorize the diff between this and cauda equina)
-Lesions at vertebral level L2 often affect the conus medullaris.
-Early and prominent sphincter dysfunction with flaccid paralysis of the bladder and rectum, impotence, and saddle (S3-S5) anesthesia.
-Causes include disc herniation, spinal fracture, and tumors
-May have some upper motor neuron (UMN) signs and present with increased tone and reflexes (UMN) and bilateral signs.
-In terms of the diagnosis, differentiating between cauda equina syndrome and conus medullaris syndrome doesn’t matter, as the management is the same. What’s needed is an MRI and urgent referral**
julia notes:
- CMS: around L1-L2 -> has UMN and LMN sx; faster onset
- CES: L2-S5 -> LMN lesion ONLY; more gradual onset, may have more assymetric sx
epidural abscess: definition, pathogenesis, risk factors
Definition: Infection within the epidural space of the spinal cord
-Any age, more often 50-70 yo
-Can lead to spinal cord compression / ischemia
Pathogenesis:
-Hematogenous spread - bacteremia
-Direct inoculation: surgery, trauma
-Mostly staph aureus infections- skin infection
Risk factors:
-25% have no risk factors
-Immunocompromise: DM, HIV, malignancy, chronic steroids, immunosuppressants
-Recent SSTI bacteremia
-Spinal anatomy abnormality
-Substance abuse: alcohol, IVDU!
-Presence of indwelling catheter
-Elderly
