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Medicine Phase 2a Neuro > Spinal cord compression and cauda equina syndrome > Flashcards

Spinal cord compression and cauda equina syndrome Flashcards

1
Q

Vertebrae in which the spinal cord is found

A

C1 (junction with medulla) to L1 (conus medullaris)

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2
Q

At what level would you take a lumber puncture

A

L4

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3
Q

Below L1 are the lumber and sacral nerve roots - grouped together, what is this called

A

Cauda equina

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4
Q

Deine paraplegia

A

Paralysis of BOTH legs always caused by spinal cord lesion

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5
Q

Define hemiplegia

A

Paralysis of ONE side of body caused by lesion of he brain

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6
Q

Signs of UMN lesion

A

Signs contralateral to lesion
Increased muscle tone (Spasticity)
Weakness (flexors generally weaker than extensors in legs and reverse in arms)
Increased reflexes, they are brisk - Hyperreflexia

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7
Q

Signs of LMN lesion

A 
Signs ipsilateral to lesion
Decreased muscle tone
Wasting/Atrophy
Fasciculations possible 
Reflexes reduced or absent
Weakness (relating to areas supplied by peripheral nerves)
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8
Q

What are fasciculations and what could they be a sign of

A

Spontaneous involuntary twitching

LMN lesion

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9
Q

Give examples of how the level of the LMN problem can be inferred from accompanying symptoms

A

Back pain/sciatica suggest a root problem
Weakness of the biceps with absence of the biceps reflex with UMN signs in the legs suggests cord disease e.g. a disc prolapse at C5/C6 (LMN at this level and UMN below)

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10
Q

What is spondylolisthesis

A

Slippage of one vertebra over the one below
Nerve root comes out ABOVE the disc therefore root affected will be the one BELOW the disc herniation e.g. L4/5 herniation leads to L5 nerve root compression

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11
Q

What is spondylosis

A

Degenerative disc disease

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12
Q

What is myelopathy

A

Spinal cord disease caused by spinal cord compression

Upper motor neurone signs e.g. spasticity, weakness, hyperreflexia

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13
Q

What is radiculopathy

A 
Caused by spinal root compression
Lower motor neurone signs e.g. decreased muscle tone, wasting, weakness and fasciculations
Pain down dermatome supplied by root
Weakness in myotome supplied by root
No UMN signs
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14
Q

Signs of acute radiculopathy (spinal root compression with no UMN signs)

A

No LMN signs as fasciculations and wasting take time to develop

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15
Q

Spinal root of Clavicle dermatome

A

C4

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16
Q

Spinal root of Nipples dermatome

A

T4

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17
Q

Spinal root of Medial side of arm dermatome

A

T1

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18
Q

Spinal root of Umbilicus dermatome

A

T10

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19
Q

Spinal root of Anterior and inner leg dermatome

A

L2-3

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20
Q

Spinal root of Knee dermatome

A

L4

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21
Q

Spinal root of Posterior and outer leg dermatome

A

L5, S1-2

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22
Q

Spinal root of Perianal area dermatome

A

S4

23
Q

What is myelopathy

A

Compression of the spinal cord resulting in upper neurone signs and specific symptoms dependent on where compression is

24
Q

Aetiology of spinal cord compression

A 
Vertebral body neoplasms (secondary malignancy)
Disc herniation
Degenerative disc
Disc prolapse
Rarer:
Infection e.g. epidural abscess
Haematoma e.g. warfarin
Primary spinal cord tumour e.g. glioma, neurobiroma
25
Q

What are the 2 parts of discs of the spinal column called

A 
Nucleus pulposus
Annulus fibrosus (surrounding)
26
Q

What is disc prolapse

A

When nucleus pulposus moves and presses against the annulus resulting in pressure on nerve root and pain.
Can produce a bulge in the disc which can cause pressure on the nerve root and thus pain

27
Q

Clinical presentation

A

Progressive weakness of the legs with upper motor neurone pattern and eventual paralysis.
Hours to days onset.
Arms affected if lesion is above thoracic spine.
Sensory loss below lesion.

28
Q

Most common cause of spinal cord compression

A

Vertebral body neoplasms (secondary to malignancy elsewhere e.g. lung, breast, prostate, myeloma, lymphoma)

29
Q

Gold standard for diagnosis of spinal cord compression

A

MRI

identifies the cause and site of cord compression

30
Q

Why should imaging for spinal cord compression not be delayed at all

A

Since irreversible paraplegia may follow if the cord is NOT decompressed

31
Q

Other investigations (other than MRI) for spinal cord compression

A

Biopsy/surgical exploration - may be required to identify the nature of any mass
Screening blood tests - FBC, ESR, B12, U and Es, Syphilis serology, LFT, PSA
CXR - if TB or malignancy (see primary tumour)

32
Q

Treatment of spinal cord compression

A

Surgical decompression of the cord.
Correction of pathology.
DEXAMETHASONE reduces oedema around the lesion.
Refer to neurosurgeons.

33
Q

Treatment of spinal cord compression - epidural abscess

A

Surgical decompression

Antibiotics

34
Q

Examples of surgical decompression of spinal cord

A

Laminectomy - removal of lamina/spongy tissue between discs to relieve pressure and thus symptoms
Microdiscectomy - removal of herniated tissue from disc

35
Q

What is the cauda equina

A

Bundle of nerve roots from the lumbar and sacral levels that branch off the bottom of the spinal cord (conus medullaris).
Nerve roots caudal (distal) to the level of the termination of the spinal cord at L1/L2.

36
Q

When does the cauda equina start

A

L1/2 (more L1)

37
Q

Cauda equina syndrome epidemiology

A

Rare, occurring mainly in adults but can
occur at any age
Occurs in around 2% of herniated discs

38
Q

Most common cause of cauda equina syndrome

A

Lumbar disc herniation at L4/5 and L5/S1

39
Q

Aetiology/Risk factors of Cauda equina

A 
Herniation of lumber disc (most commonly at L4/5 and L5/S1)
Tumours/metastases
Trauma
Infection
Spondylolisthesis
Post-op haematoma
40
Q

Pathophysiology of Cauda equina

A

Nerve root compression CAUDAL to the termination of the spinal cord at L1/2
Usually large central disc herniations at L4/5 or L5/S1 levels
Bladder function can be affected due to S1-5 nerve root compression

41
Q

Clinical presentation of cauda equina syndrome

A 
BB SAFE
Bilateral sciatica
Saddle anaesthesia 
Bladder/bowel dysfunction 
Erectile dysfunction
Variable leg weakness that is FLACCID & AREFLEXIC (LMN signs)
42
Q

*What is major difference in clinical presentation between cauda euqina and lesions higher up in the cord

A

Leg weakness is flaccid and Areflexic (LMN)

NOT spastic and hyperreflexic

43
Q

What is sciatica

A

Pain, numbness and a tingling sensation that radiates from lower back and travels down one of the legs to the foot and toes

44
Q

Cauda equina syndrome investigations

A

History and clinical examination with appropriate radiological investigation.
MRI is preferred method for diagnosis and determine level of compression and any underlying cause.
MRI scan is only way to exclude CES
Further investigations for underlying cause and focusing on localised site of compression
Urodynamic studies - may be required to monitor recovery of bladder function following decompression surgery

45
Q

Cauda equina syndrome differential diagnosis

A

Conus medullaris syndrome
Mechanical back pain or prolapsed lumber disc
Fracture of lumber vertebrae due to trauma
Spinal tumour
Spinal cord compression
Peripheral neuropathy

46
Q

What is conus medullaris syndrome

A

Conus medullaris is located above the cauda equina at T12-L2; nerve root pain is less prominent and the main features are urinary retention and constipation

47
Q

Complications of cauda equina syndrome

A

Paralysis.
Sensory abnormalities.
Bladder, bowel and sexual dysfunction.

48
Q

Management of cauda equina syndrome

A

Immediate referral to neurosurgery to relieve pressure

49
Q

Tests of specific nerve roots: L5-S1

A

Knee flexion

Or Straight leg raising

50
Q

Tests of specific nerve roots: S1-S2

A

Ankle plantar flexion (downwards)

51
Q

Tests of specific nerve roots: L4

A

Femoral stretch test

52
Q

Example surgical decompression to remove causative agent in cauda equina synrome

A

Microdiscectomy
Epidural steroid injection (more effective for leg pain)
Surgical spine fixation (if vertebrae slipped)
Spinal fusion (reduces pain from motion and nerve root inflammation)

53
Q

What is microdiscectomy

A

Removal of part of disc (may tear dura)

54
Q

50yr old nurse comes in with longstanding back pain and pain radiating down right leg to sole of right foot.
On examination there is weak plantar flexion, absent right ankle jerk, decreased sensation over lateral edge and sole of right foot
WHERE IS LESION?

A

Sciatica

Right S1 lesion due to disc prolapse placing pressure on root

Medicine Phase 2a Neuro (28 decks)

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