Spinal cord and root dysfunction

Question 1

How does spinal cord dysfunction typically present?

Answer 1

• Pain
• Sensory disturbance
• Weakness
• Sphincter dysfunction
• Sexual dysfunction

Question 2

If there is a spinal cord injury at the cervical level what would occur?

Answer 2

• Arms would be involved
• UMN features (e.g. hyperreflexia, spasticity) if central lesion

Question 3

If there is a spinal cord injury at the thoracic level what would occur?

Answer 3

• Arms would not/minimally be involved
• UMN features (e.g. hyperreflexia, hypertonia, spasticity) if central lesion

Question 4

If there is a spinal cord injury at the lumbar level what would occur?

Answer 4

• Only legs would be involved
• No UMN features

Question 5

What is affected in a cervical disc prolapse?

Answer 5

• Arm pain
• Dermatomes and myotomes involved
• LMN features e.g. hypotonia/flaccid paralysis, hyporeflexia, weakness

Question 6

What is affected in a thoracic disc prolapse?

Answer 6

Rare Thoracic pain Dermatomes affected Usually central causing myelopathy

Question 7

What is affected in a lumbar disc prolapse?

Answer 7

Leg pain Dermatomes and myotomes affected LMN features e.g. hypotonia/flaccid paralysis, hyporeflexia, weakness

Question 8

What are the clinical features of spinal claudication?

Answer 8

Usually intermittent Worse on mobilising Eases at rest + bending forwards Pain often back of thighs/calves Altered sensation Heaviness/weakness Spinal vs vascular claudication

Question 9

What are the clinical features of cauda equina syndrome?

Answer 9

Emergency! Often incomplete, even more important Time is critical Principle concern is urinary function Leg pain, often bilateral (but can resolve) Perianal sensory loss to pinprick Genital numbness, erectile dysfunction Painless urinary retention with urinary incontinence (S2-S4)

Question 10

What are red flags that would make you suspect a spinal cord injury?

Answer 10

Bilateral leg pain Thoracic back pain Weight loss, night sweats, fever Night pain Sphincter disturbance Perianal sensory loss Age <20 or >55 History of carcinoma Progressive neurological deficit Trauma Immunocompromise

Question 11

What are the clinical features of cervical myelopathy?

Answer 11

Numb clumsy hands Usually bilateral, one side may be more affected Finger tip paraesthesia Difficulty with fine motor tasks Dropping objects Reduced mobility UMN - remember Hoffman’s and Lhermitte’s sign

Question 12

What are some of the potential complications from operating on a cervical myelopathy?

Answer 12

Pain, bleeding, infection, CSF leak, nerve injury, cauda equina syndrome, instability, paralysis, failed back syndrome, medical risks (DVT, PE, MI), risk to life

Question 13

What are the clinical features of failed back syndrome?

Answer 13

Recurrence, residual compression Nerve injury Altered joint mobility Fibrosis, arachnoiditis Infection Depression, anxiety

Question 14

How is failed back syndrome treated?

Answer 14

Difficult to treat Surgery - recurrence - re-operation? Infection - antibiotics Anti-inflammatories Physiotherapy Behavioural therapy TENS - transcutaneous electrical nerve stimulation Anti-depressants Spinal cord stimulation Intrathecal pump

Question 15

How is back/neck pain treated?

Answer 15

Often degenerative No significant benefit with surgery May worsen pain Conservative management - physio, analgesia Chronic pain teams