Spinal MSK Flashcards
How many cervical nerve roots are there
8
Who gets wedge compression fractures
Old ladies (and men) with osteoporosis
Who gets burst fractures
We do! Those without osteoporosis
- burst in vertebral body
What investigation would be best to identify damage to the posterior ligaments of the spine
MRI
What kind of fracture are the elderly more likely to sustain to the spine
Wedge compression fracture due to osteoporosis
Whiplash
Neck strain flexion extension injury
–> pain
Where is the most likely spot for a spinal fracture
Junction between thorax (fixed) and lumbar (free) vertebrae
–> L1 and T12
ALTS protocol
Advanced trauma life support protocol - ABC..
What percentage of spinal fractures will have another spinal injury elsewhere
10%
Neurogenic shock
Normal circulating volume but all extremities are dilated - blood pressure drops…
Spinal shock
Damage to spinal cord
–> flaccid paralysis then start to return
Need to assess neurologically after a few days
ASIA assessment
Grade A - compete spinal cord injury - no motor or sensory function
Grade E - normal where motor and sensory are normal
Anterior cord syndrome
Affects both motor and sensory pathways
Crude sensation, movement and fine sensation are lost
Central cord syndrome
Weakness and paralysis of arms and some sensory loss
Legs are less affected (sacral sparing)
Brown-sequard syndrome
Injury to half the cord
Movement and some sensory loss below injury
Pain and temperature loss on opposite side
Spinal concussion - complete or incomplete last few hours to days
How to children differ from adults regarding trauma to the spine
Children have a larger head relative to body
Can see ossification centres/growth plates
Tough outer layer of intervertebral disc
Annulus fibrosis
Gelatinous core of intervertebral disk
Nucleus polposus
Which movements cause IV discs to fail
Twisting movements
Management of nerve root pain
Physio
Strong analgesia
Disc problems
Disc bulge
Protrusion
Extrusion
Sequestration
Sensory loss of disk L5/S1
S1 nerve root
–> little toe and sole of foot
Motor weakness due to damage of S1
Plantar flexion of foot
Which nerve is affected by L4/5 disc prolapse
L5
Sensory loss from L5 lesion
Great toe and 1st dorsal web space
Motor weakness from L5 lesion
Extensor hallucis longus
Symptoms of L4 nerve root damage
Medial aspect of lower leg sensory loss
Quadricep weakness
Which regions of the spine are most commonly affected by degeneration
Cervical and thoracic
Effect of cauda equina compression - why is it an emergency
SURGICAL EMERGENCY
Sacral nerve root compression can result in permanent bladder and anal sphincter dysfunction and incontinence
Aetiology of cauda equina syndrome
Central lumbar disc prolaps (common)
Tumours
Trauma (to spine) or spinal stenosis
Infection - epidural abscess
Iatrogenic - spinal surgery or manipulation, an epidural injection 😱
Clinical features of cauda equina syndrome
Location of symptoms - bilateral buttock and leg pain and varying dyskinesia and weakness
Bowel or bladder dysfunction (urinary retention +/- overflow incontinence)
PR exam - saddle anaesthesia (perianal loss of sensation), loss of anal tone and anal reflex
Treatment of cauda equina syndrome
Operative - 48 hours❗️
Discectomy/route of problem
Spondylosis
Degenerative change
Effect of cervical and lumbar spondylosis
If severe can compress whole cord causing myelopathy
Movements permitted at the facet joints of the vertebrae at the lumbar spine
Flexion and extension
Name the ligament on the front of the vertebral bodies
Anterior longitudinal ligament
Name the ligament along the back of the vertebral bodies
Posterior longitudinal ligament
Name the ligament between laminae
Ligamental flavum
Symptoms of spinal claudication
Bilateral (usually)
Sensory dysaesthesiae
Possible weakness - drop foot
Takes several minutes to ease after stopping walking
WORSE ON WALKING DOWNHILL BECAUSE SPINAL CANAL BECOMES SMALLER IN EXTENSION
Types of spinal stenosis
Lateral recess
Central
Foraminal
Symptoms of spondylolysis
Low back pain
Occasionally radicular symptoms
Limits hyperextension activities/sports
Comon
Stages of fracture healing
1) Inflammation - haematoma and fibrin clot, angiogenesis
2) Soft callus - until bony fragments are united by cartilage or fibrin tissue, continued increase in angiogenesis
3) Hard callus - secondary bone healing = obvious callous; rigid fixation no obvious callus = primary bone healing
4) Bone remodelling - conversion of woven bone to lamellar bone
Delayed union of fracture could be caused by
High energy injury Instability Infection Steroids/immune suppressants Smoking Warfarin NSAID
How may we help delayed healing
Different dixation
Dynamisation
Bone grafting - autogenous is best choice as allogenic has risk of disease transmission
3 main functions of spine
Support axial skeleton
Movement of truck
Protect spinal cord
Source of infection in acute osteomyelitis in infants
Infected umbilical cord
Source of infection in acute osteomyelitis in children
Boils, tonsilitis, skin abrasions
Source of infection in acute osteomyelitis in adults
UTI, arterial line
What conditions may predispose to acute haematogenous osteomyelitis
Diabetes Rheumatoid arthritis Immune compromise Long term steroid treatment Sickle cell
Acute osteomyelitis infection organisms
Staph aureus most common all ages
Infants: e.coli
Older children: strep pyogenes, haemophilus influenzae
Adults: strep pyogenase, pseudomonas aeroginosa
Responsible organism for acute osteomyelitis secondary to penetrating foot injury and IVDA
Pseudomonas aeroginosa
Pathology of acute osteomyelitis
Starts at metaphysis
Vascular status - venous congestion and arterial thrombosis
Acute inflammation - increased pressure
Abscess (supuration)
Release of pressure
Necrosis of bone
New bone formation
Resolution (or chronic osteomyelitis if not)
Clinical features of acute osteomyelitis in a child
Severe pain
Reluctant to move (neighbouring joints held flexed); not weight bearing
May be tender and inflamed
Fever and tachycardia
Malaise, fatigue, nausea, vomiting
Toxaemia
Clinical features of acute osteomyelitis in an infant
May be minimal signs or be very ill
Possibly drowsy or irritable
Metaphyseal tenderness and swelling
Decreased ROM
Positional change
Clinical features of acute osteomyelitis in an adult
Primary OM seen commonly in thoracolumbar spine fever
–> back ache
History of UTI or urological procedure
Old, diabetic, immunocompromised
Secondary often seen after open fracture, surgery
Diagnosis of acute osteomyelitis
FBC and diff WBC - neutrophil leucocytosis
ESR CRP
Blood culture - take 3
U and E - ill and dehydrated
Xray (may be normal if early) or show metaphyseal destruction
Ultrasound
Aspiration into bone
Bone scan
MRI
Define sequestrum
Osteonecrosis
Define involucrum
New bone
Differential diagnosis for acute osteomyelitis
Soft tissue infection Acute septic arthritis Trauma Acute inflammatory arthritis Transient synovitis
Rare - sickle cell disease, haemophilia
Treatment of acute osteomyelitis
Supportive for pain and dehydration
Rest and splintage
Antibiotics - empirical fluclox and benzylpen while waiting
Surgery - aspiration, drainage of abscess, debridement of dead/contaminated tissue
Complications of acute osteomyelitis
Septicaemia, death
Metastatic infection
Pathological fracture
Septic arthritis
Altered bone growth
Chronic osteomyelitis
Chronic osteomyelitis is…
Repeated breakdown of “healed” wounds
Chronically discharging sinus fixed to underlying bone
Organisms responsible for chronic osteomyelitis
Staph aureus
E.coli
Strep. Pyogenes
Proteus
Treatment of chronic osteomyelitis
Local - gentamycin cement/beads
Systemic
Eradicate bone infection surgically
Treat soft tissue problems
Correct deformity/reconstruct
Consider amputation
Complications of chronic osteomyelitis
Ongoing metastatic infection - abscesses
Pathological fracture
Growth disturbance and deformities
Amyloidosis
Route of infection in acute septic arthritis
Direct invasion via penetrating wound or intra-articular injury
Eruption of bone abscess
Haematogenous spread
Organism in acute septic arthritis
Staph aureus
Haemophilus influenzae
Strep pyogenes
E.coli
Presentation of acute septic arthritis in a neonate
Picture of septicaemia
- irritability
- resistant to movement
- ill
Presentation of acute septic arthritis in child
Acute pain in single large joint
- reluctant to move
- increase temp and pulse
- increase tenderness
Investigations for acute septic arthritis
FBC, WBC, ESR, CRP, blood cultures
Xray
Ultrasound
Aspiration
Most common cause of acute septic arthritis in an adult
Infected joint replacement
Differential diagnosis for septic arthritis symptoms
Acute osteomyelitis
Trauma
Irritable joint
Haemophilia
Rheumatic fever
Gout
Treatment of acute septic arthritis
General supportive
Antibiotics
Surgical drainage and lavage
Clinical features of tuberculosis
Insidious onset and general ill health
Contact with TB
Pain (esp. At night), swelling, loss of weight
Low grade pyrexia
Joint swelling
Decreased ROM
Ankylosis
Deformity
Polymyalgia rheumatica is characterised by
Pain and stiffness in the shoulders, neck, hips and lumbar spine, which is worse in the morning
It is rare in the under 60s
Most specific investigation for rheumatoid arthritis is
Anti-citrullinated peptide antibodies
However is not routinely performed before taking rheumatoid factor - send for anti-CCP if rf is negative or to judge course
First line therapy for rheumatoid arthritis
Non steroidal anti inflammatory drugs
Which joints of the hand are usually spared at the beginning of rheumatoid arthritis
Distal interpharyngeal joints
When is the pain generally worse in osteoarthritis
The evenings
Heberden’s and bouchard nodes are features of what
Osteoarthritis
Heb = DIP Bouchard = PIP
Main radiographical features of osteoarhritis are
Reduced joint space
Subchondral sclerosis
Bone cysts
Osteophytes
Radiographical features of rheumatoid arthritis
Reduced joint space
Soft tissue swelling
Peri-articular osteopenia
Bony erosions
Joint subluxation
Management of someone presenting to A&E with suspected septic arthritis
Aspiration and blood culture
Empirical antibiotic treatment IV - benzylpen and fluclox
Immobilise joint
Perform an Xray
Physio for follow up
Clinical features of reactive arthritis
Acute assymetrical lower limb arthritis occurring 1-4 weeks following an infection (dysentery or urethritis)
Conjunctivitis
Enthesitis which may result in plantar fasciitis or archilles tendonitis
Ulceration of the glans penis
Nail dystrophy
Mouth ulcers
Aortic incompetence (rarely)
Treatment of reactive arthritis
NSAIDs and local steroid injection for symptomatic control
Psuedo-gout is caused by the presence of what crystals
Calcium pyrophosphate
Which condition presents with rhomboidal, weakly positive bifringent crystals under polarised light microscopy of joint fluid
Pseudo-gout
How does gout present under polarised light microscopy of joint fluid
Needle-shaped negatively birefringent crystals
Why might someone with rheumatoid arthritis get pulmonary fibrosis
How would this present
Extra articular manifestations
And is a side effect of methotrexate (DMARD)
–> shortness of breath, fine basal inspiratory crepitations and dry cough
Anti-phospholipid syndrome
Recurrent arterial or venous thrombosis with a history of miscarriages
Can occur secondary to SLE
