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*Medicine: Neurology > Spinal Disorders > Flashcards

Spinal Disorders Flashcards

1
Q

What is the anatomy of the vertebral column?

A
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2
Q

What is the anatomy of the spinal cord?

A
  • approx 45cm long
  • originates from medulla
  • through foramen magnum
  • ends as conus medullaris (L1-2 in adult)
  • cauda equina - motor + sensory nerve roots exiting through lumbar and sacral foramina
  • meningeal coverings of cord continuous with brain
  • cord closely ensheathed by pia mater
  • pia mater forms denticulate ligaments
  • space between arachnoid + pia → CSF
  • dura forms tough sheath; ends distally at S2
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3
Q

More anatomy of the spinal nerves

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4
Q

Anatomy of the intervertebral disc

A
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5
Q

Describe the dermatome distribution of the upper and lower limb

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6
Q

What movements are supplied by which nerve roots in the upper limb?

A
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7
Q

Which are the myotomes of the lower limb?

A
  • Hip flexion → L1-2
  • Knee extension → L3
  • Ankle dorsiflexion → L4
  • Ankle plantarflexion → S1-2
  • Foot inversion → L4
  • Foot eversion → S1
  • Big toe dorsiflexion → L5
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8
Q

What are the ascending (sensory) tracts of the spinal cord?

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9
Q

What are the descending (motor) tracts of the spinal cord?

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10
Q

What does the spinal cord look like on MRI?

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11
Q

What red flags are important to look out for when taking a history for back pain / spinal disorders?

A
  • extremes of age <20 / >50
  • Hx of cancer
  • unexplained weight loss
  • immunosuppression
  • IV drugs, steroids
  • trauma
  • faecal incontinence / loss of anal sphincter tone
  • saddle anaesthesia
  • globa/progressive weakness in legs
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12
Q

Why is spinal cord compression an emergency?

A
  • requires swift management to prevent irreversible spinal cord injury + long-term disability
  • treatment of acute compression → corticosteroids, surgery, radiotherapy
  • diagnosis → x-ray or MRI of spine
  • spinal cord injury may occur w/ no findings on imaging
  • may be acute, sub-acute, chronic
  • occurs due to:
    • direct cord damage → compression and/or infiltration
    • cord vascular supply compromise
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13
Q

Which part of the spinal cord is most commonly injured?

A
  • Cervical (C1-T1) → 55%
  • Thoracic (T1-T11) → 15%
  • Thoracolumbar (T11-L2) → 15%
  • Lumbosacral (L2-S5) → 15% (not cord, cauda equina)

There is a roughly equal distribution between complete and incomplete paraplegia/quadriplegias. Mortality risk is higher in C1-3 compared to C6-8.

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14
Q

What are the causes of spinal cord compression?

A
  • trauma (main cause) → RTAs, falls, sports, knife/gunshot wounds, spontaneous disc protrusions, iatrogenic
  • malignancy → extradural, intradural, primary + secondary
  • infection → discitis, abscesses, osteomyelitis
  • haematoma → AVM, spontaneous, trauma
  • cystic lesions → arachnoidal, syringomyelia
  • pathological fractures → osteoporosis, steroid therapy
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15
Q

Which tumours are most likely to metastasise to the bone?

A

‘BLT Plus Ketchup’

  • Breast
  • Lung
  • Thyroid
  • Prostate
  • Kidney
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16
Q

What are signs and symptoms of spinal cord compression?

A
  • back pain → associated w/ malignancy, compression fractures, infection etc
  • sensory → numbness or parasthesia
  • motor → weakness or paralysis, hypotonia
  • autonomic → bladder or bowel dysfunction
  • spasticity → most often w/ malignancy
  • neurogenic shock → if lesions in C-spine, hypotension, bradycardia, warm extremities
  • Brown-Sequard syndrome
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17
Q

What is the pathophysiology of spinal cord injury?

A
  • injury arises from stretching or from pressure
  • injures white matter (myelinated tracts) + grey matter (cell bodies) in cord
  • causes loss of some sensory modalities + motor function
  • spinal cord nerve roots depend on constant blood supply for appropriate energy stores + substrate, to perform axonal signalling
  • conditions that interfere either directly or indirectly w/ blood supply will cause malfunction of transmission pathway
  • nerve tracts most vulnerable to mechanical pressure include corticospinal + spinocerebellar tracts, and posterior spinal columns
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18
Q

Spinal cord injury can be classified as complete and incomplete.

What is meant by this?

A
  • INCOMPLETE → any residual motor or sensory function more than 3 segments below level of injury; sensation or voluntary mvmt in legs; sacral sparing; types of lesion = central cord/Brown Sequard/anterior cord/posterior cord
  • COMPLETE → no preservation of any motor and/or sensory function more than 3 segments below level of injury; no voluntary anal contraction; no anal sensation; no s4/5 sensation

Complete cord transection syndrome results in a group of symptoms known as spinal shock + when seen at high cervical level → quadriplegia, resp insufficiency, loss of bladder/bowel fxn, anaesthesia below affected level + neurogenic shock.

ASIA classification for pts w/ acute traumatic spinal cord injury.

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19
Q

Transverse myelitis (TM) is a pathogenetically heterogeneous focal inflammatory disorder of the spinal cord. Leads to axonal demyelination. Thought to be viral.

How does it clinically present?

A
  • age 10-10 or 30-39
  • motor weakness
  • paraesthesias or sensory loss
  • bladder → urinary frequency, urgency, incontinence, retention
  • bowel → incontinence or constipation
  • L’hermitte sign → tingling in limbs on neck flexion
  • paroxysmal tonic spasms → painful, involuntary limb spasms
  • UMN signs → hyper-reflexia, Babinski +ve, spasticity
  • back / trunk / limb pain
20
Q

What are differentials for the patient “off their legs”?

A
  • Transverse myelitis
  • Guillain-Barre syndrome
  • HIV-related myelopathy
  • Amyotrophic lateral sclerosis
  • Multiple Sclerosis
  • Diabetic neuropathy
  • Polymyositis
  • Hereditary muscular dystrophy
  • Peripheral neuropathy
  • Cerebellar origin (ataxia)
  • Spinal cord (stenosis / malignant compression / syringomyelia)
  • Degenerative ataxias
  • Metabolic/Nutritional (vit B12 def/drugs/dizziness)
21
Q

What are the investigations for spinal cord compression?

A
  • CT for bony anatomy
  • MRI for soft tissue (cord itself)
  • CXR, X-ray spine, FBC, U+E, bone profile, ESR, CK, TFTs, plasma electrophoresis, urine (Bence-jones protein), ABPI

Investigate the rest of the body also - is it cancer (primary or mets)? Is it infection (source)? Is it bony degeneration (osteoporosis)? Is it trauma? Any other injuries?

22
Q

What do MRI findings of spinal cord injury look like?

A
23
Q

Clinical features depend on the site, level and completeness of the compressive lesion. Any residual motor or sensory function more than 3 segments below the level of injury suggest an incomplete lesion - look for signs of preserved long tract function.

What are 5 types of incomplete injury?

A
  • Central cord syndrome
  • Anterior cord syndrome
  • Brown-Sequard syndrome
  • Posterior cord syndrome
  • Cauda Equina syndrome

Whereas, complete lesions show no preservation of motor and/or sensory function more than 3 segments below the level of injury.

24
Q

With any severe, acute spinal cord lesion there are usually two clinical stages. What are these?

A
  • Spinal shock → initially, there is loss of all reflex activity below level of lesion w/ flaccid limbs, atonic bladder + overflow incontinence, atonic bowel, gastric dilatation and loss of genital reflexes + vasomotor control
  • Heightened reflex activity → occurs after about 1-2wks + is associated w/ spasticity of limbs, brisk reflexes and extensor plantar responses. Pts develop a spastic bladder (small capacity w/ urgency and frequency, and autonomic emptying) and hyperactive autonomic function (sweating + vasomotor changes)
25
Q

A disc protrusion occurs when the disc nucleus bulges but does not rupture. The nucleus remains contained within the disc structure.

What causes disc protrusion and how does it present?

A
  • most common cause of disc disease → spondylosis
  • degenerative changes within vertebrae + intervertebral discs occur during ageing or secondary to trauma or rheum disease
  • damaged discs normally protrude laterally + cause compression of nerve roots → LMN lesion
  • discs can protrude centrally + posteriorly → results in cord compression when it occurs above level of L1 + causes a spastic paraparesis (usually low cervical or thoracic disc) or tetraparesis (high cervical disc) w/ variable sensory loss + sphincter dysfunction
26
Q

What are the features of central cord syndrome?

A
  • most common type of injury
  • usually follows hyperextension injury in presence of osteophytic spurs, often in older people
  • motor deficit → upper limb >>> lower limb → weak arms (more than legs)
  • surgery often employed for ongoing compression (non-emergency)
  • pathophys → centremost region of spinal cord is a vascular watershed zone - more susceptible to injury from oedema; long tract fibres in cervical cord are somatotopically organised such that upper limbs are more medial than lower limbs
  • sensory → varying degrees of disturbance below level of lesion; “suspended sensory loss”; “cape like distribution”; myelopathic findings include sphincter dysfunction (urinary retention)
27
Q

What are the features of anterior cord syndrome?

A
  • cord infarction in region supplied by anterior spinal artery
  • paraplegia; quadriplegia if above C7
  • dissociated sensory loss → loss of pain + temp; preserved dorsal columns
  • causes → occlusion of anterior spinal artery; dislocated bone fragment; traumatic herniated disc
  • worst prognosis of the incomplete injuries
  • only 10-20% recover functional motor control
  • sensation may return enough to help prevent injuries (burns, ulcers)
28
Q

What are the features of Brown-Séquard syndrome?

A
  • partial (unilateral) cord lesion
  • laterally placed lesion causing compression on one side - spinal cord hemisection
  • ipsilateral findings → motor paralysis (corticospinal tract lesion) below level of lesion; loss of posterior column fxn (proprioception + vibration)
  • contralateral findings → dissociated sensory loss; loss of pain/temp below level of lesion (begining 1-2 segments below) (spinothalamic tract); preserved light touch due to redundant ipsilateral + contralateral paths (anterior spinothalamic tract)
29
Q

What are the features of posterior cord syndrome?

A
  • AKA “contusio cervicalis posterior”
  • rare!
  • produces pain + paraesthesia (often without a burning quality) in the neck, upper arms + torso
  • may be mild paresis of upper limbs
  • long tract findings are minimal
30
Q

Cauda equina syndrome results from compression of the cauda equina nerve roots. It can be caused by any compressive lesion below L1/L2 - prolapsed disc, tumour, abscess, trauma and haematoma.

What is the clinical presentation?

A
  • leg pain → bilateral +/- lower back pain
  • sacral anaesthesia +/- loss of anal reflex
  • urinary retention w/ overflow incontinence
  • motor weakness of L4, L5, S1 + S2
  • sexual dysfunction

Triad of leg pain, saddle anaesthesia and urinary disturbance isn’t always the case - any pt who has sensory disturbance in S2/3/4 should have high index of suspicion - have a low threshold for scanning → lumbar spine MRI

Timing of symptom onset is critical bc it influences timing of surgery ie. the longer symptoms present, the less likely to regain function. Completeness of symptoms also important as strongly correlated w/ recovery potential - pts having incomplete cauda equina have a better prognosis.

Rx → urgent surgery in form of laminectomy

31
Q

What are the main goals of treatment for spinal cord injury?

A
  • to prevent clinical deterioration from progressive degenerative changes of spinal cord injury
  • to relieve pain + symptoms
  • to restore functional ability

The following groups can be considered in the treatment approach → acute, traumatic SCI; epidural abscess; malignant SCC; intervertebral disc compression

32
Q

Acute traumatic SCI is a medical emergency and management should be undertaken at a trauma centre w/ experience in SCI and in-house neurosurgical expertise.

What is the management of (traumatic) spinal cord compression?

A
  • ABCDE
  • immobilisation w/ cervical collar + backboard/head strap while clinical exam/imaging done
  • confirmed spinal injury? → refer for neurosurg evaluation for decompression + stabilisation within 24hrs
  • monitor pt in ICU → cardiac / haemodynamic / resp monitoring
  • management depends on site + stability of injury**
    • unstable → risks further damage to spinal cord + roots, requires operative fixation eg. screws/rods or non-surgical immobilisation eg. traction, HALO or plaster jacket
    • stable → can try to manage conservatively eg. w/ rigid collar
  • after initial management, pt may require long-term spinal rehab so transfer to appropriate speicalised spinal injury centre

**Stability = ability of the spine under physiological loads to limit displacement as to prevent injury or irritation of the spinal cord and nerve roots and to prevent incapacitating deformity or pain due to structural changes

33
Q

What are other considerations/further management for traumatic spinal cord compression, following initial management?

A
  • DVT/PE prevention
  • steroids → high-dose methylprednisolone (given within 8hrs)
  • treatment of autonomic dysfunction + prevention of hypotension
  • NG tube (prevent vomiting/aspiration)
  • prevention of gastric stress ulceration
  • supportive therapies:
    • nutritional support
    • mechanically assisted ventilation or manually assisted cough
    • bladder + bowel management: catheterisation/laxatives/bowel evacuation
    • pressure sore prevention: regular turning + physio
34
Q

What is the specific management of an epidural abscess, in relation to spinal cord compression?

A
  • same principles as trauma → does spinal cord need decompression? does spine need stabilisation?
  • take sample of abscess during surgery → send to lab for MC+S
  • treat w/ empirical ABx initially then adjust according to culture results
  • ABx treatment advised for at least 12 weeks
  • pathogens → Staph aureus (most common)
  • identify underlying source of infection
    • dental X-rays
    • cardiac ECHO
    • swabs from any wounds
    • blood cultures
    • urine culture
35
Q

Malignanct spinal cord compression is one of the most devastating + dreaded complications of cancer. Occurs in 5% of all cancer patients and amounts for 50% of adult acute myelopathies. Rapid neuro deterioration can result in paralysis and loss of sphincter function.

Early diagnosis + treatment of condition is vital to keep patients ambulatory and thus have a positive impact on quality of life.

We mentioned the source of primary cancerous sites previously, where do these metastasize to in the bone most commonly?

A
  • thoracic most often
  • usually involves vertebral body + pedicles
36
Q

MSSC: All patients should be referred to specialist neuro-onco spinal MSCC teams for discussion. All patients require steroids + biopsy if no prior diagnosis exists. Steroids provide relief from pain, reduce tumour-associated oedema and may be oncolytic for some tumours.

What are factors supporting the following methods of treatment?:

  • decompressive suergery (plus radiotherapy)
  • just radiotherapy
A
37
Q

What are features of the intervertebral disc?

A
  • function → permit stable motion of spine while supporting + distributing loads under movement
  • annulus fibrosus → multilaminated ligament encompasses periphery of disc space, tough + collagenous
  • nucleus pulposus → jelly like, central portion, remnant of notochord
  • ageing → w/ age the nucleus becomes less hydrated + more collagenous, it discolours, changing from white to yellow-brown in colour through accumulation of product of non-enzymatic glycosylation; these reduce flexibility
38
Q

What is a myelopathy and its common features?

A
  • pathological condition of spinal cord
  • clinical features depend on which level affected + extent (anterior, posterior, lateral) of the pathology
  • may include:
    • UMN signs (weakness, spasticity, clumsiness, altered tone)
    • pathological hyperreflexia + upgoing plantars
    • sensory deficits
    • bowel/bladder symptoms + sexual dysfunctions
39
Q

What is a radiculopathy and its common features?

A
  • pathological condition of nerve root
  • pain in distribution of that nerve root
  • dermatomal sensory disturbances
  • weakness of muscle innervated by that nerve root
  • hypoactive muscle stretch reflexes of same muscles
40
Q

Disc prolapse is the most common cause of nerve root compression.

What is disc prolapse and who is at risk?

A
  • ie. slipped disc
  • occurs when outer ring becomes weak or torn + allows inner portion to slip out
  • this can happen w/ age or certain motions may also cause it, esp twisting or turning to lift an object
  • overweight individuals are also at increased risk bc their discs must support additional weight
  • more common in men
  • rupture usually occurs in posterior-lateral direction
41
Q

Sciatica is the most common lesion in the lumbar region causing compression of L5 and S1 roots due to lateral prolapse of L4/5 and L5/S1.

What are the clinical features of sciatica?

A
  • back pain progressing to leg pain, radiating down buttock
  • pain worse on coughing
  • weakness + numbness
  • bladder problems
  • paravertebral muscle spasm
  • antalgic gait
  • reduced passive straight leg raise
  • motor + sensory disturbance dependent on level, eg. weak EHL (L5)
42
Q

For sciatica, investigations include MRI, nerve conduction studies and myelography.

What is the treatment for sciatica?

A
  • conservative management → analgesia, physio
  • pain clinic → nerve root injections / epidural injections
    • 85% w/ acute disc herniation will improve without surgery in 6wks
    • 70% within 4 weeks
  • surgical treatment → lumbar decompression (discectomy/microdiscectomy), indicated if:
    • failed conservative treatment
    • severe pain
    • progressive motor deficit
    • cauda equina syndrome
43
Q

Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk prolapse or other similar degenerative changes.

What clinical features will patients present with?

A
  • back pain
  • neurogenic claudication → progressive bilateral leg pain, numbness, weakness
  • limitation of walking distance
  • postural relief → sitting is better than standing + pt may find it easier to walk up rather than downhill
  • bladder symptoms
  • examination may be unremarkable
44
Q

What is the pathophysiology of lumbar spinal stenosis?

A

Degenerative disease is the commonest underlying cause. Degeneration is believed to begin in the intervertebral disk where biochemical changes such as cell death and loss of proteoglycan and water content lead to progressive disk bulging and collapse.

This process leads to an increased stress transfer to the posterior facet joints, which accelerates cartilaginous degeneration, hypertrophy, and osteophyte formation; this is associated with thickening and distortion of the ligamentum flavum.

The combination of the ventral disk bulging, osteophyte formation at the dorsal facet, and ligamentum flavum hyptertrophy combine to circumferentially narrow the spinal canal and the space available for the neural elements. The compression of the nerve roots of the cauda equina leads to the characteristic clinical signs and symptoms of lumbar spinal stenosis.

45
Q

What are the investigations and treatment for lumbar spinal stenosis?

A
  • INVESTIGATIONS → Plain X-Ray and MRI (most accurate)
  • CONSERVATIVE MX → analgesia, physio, osteopathy, chiropractic, facet joint injections, epidural injections
  • SURGERY MX → lumbar laminectomy, laminectomy + fusion, interspinous distraction procedure
46
Q

Degenerative cervical myelopathy (DCM) has a number of risk factors, which include smoking due to its effects on the intervertebral discs, genetics and occupation - those exposing patients to high axial loading.

What are the clinical features of cervical myelopathy?

A
  • pain → neck, upper or lower limbs
  • loss of motor function → digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait + balance
  • loss of sensory fxn → urinary or faecal incontinence + impotence
  • Hoffman’s sign → reflex test to assess for cervical myelopathy: gently flick one finger on a patient’s hand, a positive test results in reflex twitching of the other fingers on the same hand in response to the flick

MRI of spine is gold standard → may reveal disc degeneration + ligament hypertrophy w/ accompanying cord signal change.

47
Q

As with lumbar disc herniation, cervical disc herniation can cause compression of the nerve root. This results in radicular pain down the arm in the corresponding dermatome (brachalgia).

What are other features of cervical radiculopathy?

A
  • almost all herniated cervical discs cause painful limitation of neck movement
  • some pts find relief elevating arm + cupping back or top of head with their hand
  • Lhermitte’s sign → electric-shock like sensation radiating down spine may be present
  • Spurling’s sign → radicular pain reproduced when examiner exerts downward pressure on vertex tilting head towards sympomatic side, this causes narrowing of intervertebral foramen + possibly increases disc bulge

*Medicine: Neurology (21 decks)

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