Spinal Cord Compression/ cauda equina/ radiculopathies/ spondylosis/carpal tunnel etc...

Question 1

What is the clinical presentation of someone with cord compression?

Answer 1

The presentation depends on the location of the lesion and the extent to what it impinges on it

Compression before T1= tetraplegia (all 4 limbs)

Compression after T1= paraplegia

More mild compression- weakness, paraesthesia (altered sensation- pain, numbness, pins and needles)

Sensory, motor, autonomic dysfunction

Question 2

What are the red flag symptoms in terms of cord compression?

Answer 2

Weakness
Paraesthesia
Ataxia
Urinary retention
UMN signs (clonus, hyperreflexia 

Remember to always consider metastatic disease in high risk patients presenting with back pain

Question 3

What cancers commonly metastatise to bone?

Answer 3

Can be remembered as the 5B’s…

• breast
• bidney
• bronchus
• byroid
• brostate

Question 4

What is the presentation of CES?

Answer 4

Most cases are sudden onset and evolve over hours and days

They require the following for diagnosis-

• saddle (perianal) paraesthesia
• impairement of bladder, bowel and sexual function

Other symptoms which present more inconsistently;

Loss of lower limb reflexes
Loss of anal tone
Lower limb weakness and sensory deficit which is often asymmetrical

Question 5

What is the difference between CES- I and CES- R?

Answer 5

CES-I = incontinence
Reduced urinary sensation, reduced desire to void, poor stream

CES-R = retention
Compression has been sufficient to cause overflow and incontinence

Question 6

Will CES cause LMN or UMN picture?

Answer 6

LMN

Question 7

How do you diagnose CES?

Answer 7

Hx
MRI is the modality of choice(CT myelogram is an alternative to MRI)
Referall to the surgical unit

Question 8

How should you manage cauda equina?

Answer 8

Urgent referral to neurosurgical department
Surgical decompression within 48 hours of onset of symptoms

Some aetiologies can be treated non surgically.

• metastatic disease can be treated with radiotherapy
• ankylolysing spondylitis can be treated with anti- inflammatories (steroids)
• infective focus can be treated with antibiotics

Question 9

What is CES a result of?

Answer 9

Compression of lumbosacral nerve roots, commonly due to prolapse at the L4/5 discs

Question 10

What are the dorsal columns?

Answer 10

They sit dorsally in the spinal cord

Carry information about fine touch, proprioception, vibration

Question 11

What so they anterolateral pathways carry?

Answer 11

Spinothalamic tracts

Carry Information from the peripheries- pain and temperature

Question 12

What do the lateral corticospinal tracts carry?

Answer 12

Afferent signals

- from the motor cortices downwards to mediate voluntary movements in peripheral musculature

Question 13

What is the route of the posterior columns?

Answer 13

Posterior columns= politically correct

Some doctors think politically

Sensory neuron —> dorsal column —> medulla (cross here)—> thalamus —> primary sensory cortex

Question 14

What is the course of upper motor neurones

Answer 14

They begin the primary motor cortex, before going to the internal capsule, through the medullary pyramid where it splits into anterior and lateral corticospinal tracts (90% of corticospinal tracts) and then from the lateral corticospinal tract to the muscle

Before they go to the muscle they synapse at the anterior horn

PPLM (prickly plants lack moisture)

Primary motor —> medullary pyramids —> Lateral corticospinal tracts —> movement

Question 15

If the lateral spinothalamic tract was injured, where would pain/temperature be affected?

Answer 15

Pain/ temperature would be affected 2-3 segments contralateral below where the injury was

Question 16

What is cervical/ lumbar spodylosis?

Answer 16

Degenerative disc disease refers to the natural deterioration of the intervertebral disc structure, such that they become progressively weak and begin to collapse. While many patients remain asymptomatic, a proportion will develop pain and further complications.

Question 17

How does spondylosis present?

Answer 17

Early stage disease-
Symptoms often localised, clinical examination may be unremarkable
Local spinal tenderness
Contracted paraspinal muscles
Hypomobility
Painful extension of back or neck 

All cases require a complete neurological examination to assess for evidence of spinal cord compression or cauda equina syndrome

When the disc degeneration progresses to cause instability, the pain may become more severe and include radicular leg pain or paraesthesia

Pain may be reproduced by passively raising the extended leg (positive lasegue sign)

Further disease progression- tenderness, stiffness, reduced movement, scoliosis

Question 18

How do you manage spondylosis?

Answer 18

Management of degenerative disc disease is highly variable and patient-dependent*.

In the acute stage of disc disease, adequate pain relief is the mainstay of treatment. Simple analgesics should be used first-line, with neuropathic analgesics as adjuncts if required.

Encouraging mobility within patient limits is recommended for the treatment of acute low back pain, with physiotherapy for strengthening exercises.

*Emergency intervention is only warranted in cases of cauda equina syndrome, necessitating decompression of the spinal canal within 24-48 hrs of symptom onset, through commonly either laminectomy or discectomy

If pain continues beyond 3 months, despite analgesia, referral to the pain clinic may be required.

Although spinal fusion has previous been suggested for chronic low back pain, there is no evidence to support surgical intervention (indeed, evidence suggests surgery may make back pain worse in the long term).

Question 19

What is radiculopathy?

Answer 19

Damage to the nerve root by any cause or at any point once it has left the spinal cord.

Question 20

What is the most common cause of radiculopathy?

Answer 20

Spondylosis

Question 21

What are the causes of radiculopathy?

Answer 21

Spondylolisthesis (slipped disc)
Degenerative disc disease
Herniated disc
Spinal stenosis 
OA
Bone spurs 
Spondylosis

Question 22

How does radiculopathy present?

Answer 22

Because it affects the nerve route, the patient will experience in the symptoms in that spinal nerve

Can either be bilateral (if large herniation) or unilateral

Normally a gradual presentation

• pain
• paraesthesia
• loss or proprioception
• weakness
• muscle atrophy
• altered deep tendon reflexes

Cauda equina= radiculopathy of the lumbar and sacral nerve roots as they descend beyond the conus medullaris (lower end of the spinal cord)

Question 23

What are the ix for radiculopathy?

Answer 23

MRI is gold standard, however CT is used for patients with pace makers, spinal cord stimulators
Nerve conduction studies and electromyography used as an adjunct when not sure if looking at peripheral neuropathy or radiculopathy

Question 24

What are the ddx for radiculopathy?

Answer 24

Torticolis 
Referred Pain
Whiplash injury 
MN disease
Rotator cuff 
Myopathy
Polyneuropathy 
Mononeuropathy

Question 25

What tests can be done on examination of a patient with radiculopathy?

Answer 25

Spurling’s test can be done for cervical radiculopathy- produces pain in the ipsilatedal dermatome

Lasegues sign- can be done for lumbosacral radiculopathy (straighten the leg until pain is felt in the buttock, leg, calf) record the angle at which the pain occurs, normal is 80-90 degrees
It is positive if the patients leg can only be lifted to 45 degrees or less before pain occurs.

Question 26

How do you treat radiculopathy?

Answer 26

Most cases are self limiting
Immobilisation 
Anti inflammatory meds can be used
Physical therapy 
Cervical traction 
Epidural steroid injections 

Patients who have persistent symptoms need surgery with the goal being the removal of tissue such as: disc fragments and/or osteophytes (bony overgrowths) in order to create more space for the nerves to exit the spinal canal

Decompressive surgery
Most common procedure= anterior cervical disectomy and fusion