Spinal Cord Disease, Intervertebral Disc Prolapse and Nerve Root Compression

Question 1

Clinical features of spinal cord compression

Answer 1

Acute upper motor neurone signs and sensory disturbance below the level of the lesion

Deep and localised back pain

Stabbing radicular sensory disturbance at the level of the lesion

Bladder and bowel involvement also common

Question 2

Causes of spinal cord compression

Answer 2

Trauma

Neoplasia

Infection (TB in at-risk patients)

Disc prolapse

Epidural haematoma

Spinal stenosis

Question 3

Management of spinal cord compression

Answer 3

Surgical decompression within 48hrs

If malignancy found - dexamethasone 16mg PPI cover

Question 4

Investigations in nerve root compression

Answer 4

Urgent whole spine MRI

Question 5

Define cauda equina syndrome

Answer 5

Compression of nerve roots of cauda equina

Medical emergency

Question 6

Causes of cauda equina syndrome

Answer 6

Herniated disc at L4/L5 and L5/S1(the most common cause)

Tumours, particularlymetastasis

Spondylolisthesis(anterior displacement of a vertebra out of line with the one below)

Abscess(infection)

Trauma

Iatrogenic (manipulation, spinal anaesthesia, post-op haematoma)

Question 7

Clinical features of cauda equina syndrome

Answer 7

Lower back pain associated with alternating or bilateral radicular pain and saddle anaesthesia (often manifests as inability to feel toilet paper when wiping)

Bladder and bowel disturbance (either constipation/retention or incontinence)

Question 8

Red flags for cauda equina syndrome

Answer 8

Saddle anaesthesia(“does it feel normal when you wipe after opening your bowels?”)

Loss of sensationinbladderandrectum(not knowing when they are full)

Urinary retentionorincontinence

Faecal incontinence

Bilateral sciatica

Bilateral or severe motor weaknessin the legs

Reduced anal toneon PR

Question 9

Management of cauda equina syndrome

Answer 9

Immediate hospital admission

Emergency whole spine MRIto confirm or exclude

Aim to surgically decompress within 48hrs

Neurosurgical inputto considerlumbar decompression surgery

Question 10

Differentiating metastatic spinal cord compression and cauda equina syndrome

Answer 10

Cauda equina presents with LMN signs (reduced tone and reduced reflexes)

MSCC compresses higher up resulting in UMN signs (increased tone, brisk reflexes and upping plantar responses)

Question 11

Define spinal stenosis

Answer 11

Narrowing of part of thespinal canal, resulting in compression of thespinal cordornerve roots

Question 12

Presentation of spinal stenosis

Answer 12

Gradual onset

Symptoms may be subtle

Severe compression can present with features ofcauda equina syndrome

Intermittent neurogenic claudication(pseudoclaudication) results in lower back pain, buttock and leg pain and leg weakness

Symptoms absent at rest and when seated but occur with standing and walking

Symptoms ofsciatica

Question 13

Spinal stenosis vs peripheral arterial disease

Answer 13

Similar symptoms

ABPI will be normal in spinal stenosis

Question 14

Investigations in spinal stenosis

Answer 14

MRI

ABPI and CT angio to exclude peripheral arterial disease if symptoms of intermittent claudication present

Question 15

Management of spinal stenosis

Answer 15

Exercise and weight loss (if appropriate)

Analgesia

Physiotherapy

Decompression surgery where conservative treatment fails

Laminectomy

Question 16

Symptoms of dorsal column lesion

Answer 16

Loss vibration and proprioception

Tabes dorsalis, SACD

Question 17

Symptoms of spinothalamic tract lesion

Answer 17

Loss of pain, sensation and temperature

Question 18

Symptoms of central cord lesion

Answer 18

Flaccid paralysis of upper limbs

Question 19

Symptoms of cord compression

Answer 19

UMN signs

Malignancy

Haematoma

Fracture

Question 20

Symptoms of Brown-sequard syndrome

Answer 20

Hemisection of spinal cord

Ipsilateral paralysis

Ipsilateral loss of proprioception and fine discrimination

Contralateral loss of pain and temperature