spinal orthopaedics

Question 1

what level does the spinal cord end and what does it become ?

Answer 1

L1

ends as conus medlars

Question 2

what are the different upper limbs myotomes ?

Answer 2

C5 - shoulder abduction (deltoid)
C6 - elbow flexion/wrist extensors (biceps)
C7 - elbow extensors (triceps)
C8 - long finger flexors (FDS/FDP)
T1 - finger abduction (interossei)

Question 3

what are the lower limb myotomes ?

Answer 3

L2 - hip flexion, Iliopsoas
L3/4 - knee extension, quads
L4 - ankle dorsiflexion, tib anterior
L5 - big toe extension, EHL
S1 - ankle plantar flexion, gastrocnemius

Question 4

what percentage of people with vertebral fracture/dislocation have spinal cord injury ?

Answer 4

15%

Question 5

what is the most common cause of spinal cord injury ?

Answer 5

fall 41.7%

RTA 36.8 %
sport 11.6%

Question 6

what constitutes a complete spinal cord injury ?

Answer 6

no motor or sensory function distal to lesion
no anal squeeze
ne sacral sensation
ASIA Grade A
no chance of recovery

Question 7

what is the grading system for SCI ?

Answer 7

ASIA classification

Question 8

what are the different grades of the ASIA classification ?

Answer 8

A - complete, no sensory/motor preserved in sacral segments
B - incomplete, sensory present, motor not below level and sacral segments
C - incomplete, motor preserved below level, key muscles <3
D - incomplete, motor preserved below, key muscles >3
E - normal motor and sensory function

Question 9

what is tetraplegia (quadriplegia) ?

Answer 9

partial or total loss of use of all four limbs and the trunk

loss of motor/sensory function in cervical segments of the cord

Question 10

what is spasticity ?

Answer 10

increased muscle tone
UMN lesion
spinal cord and above >L1

Question 11

what is paraplegia ?

Answer 11

partial or total loss of use of the lower limbs

loss of motor/sensory in thoracic, lumbar or sacral

Question 12

who gets central cord syndromes ?

Answer 12

older patients - arthritic neck
hyperextension injury
most common type

Question 13

what are features of central cord syndrome ?

Answer 13

centrally cervical tracts more involved
weakness of arms > legs
perianal sensation and lower extremity power preserved

Question 14

what is the mechanism of injury for anterior cord syndrome ?

Answer 14

hyeprflexion injury
anterior compression fracture
damaged anterior spinal artery

Question 15

what are features of anterior cord syndrome ?

Answer 15

profound weakness
fine touch and proprioception preserved
poor prognosis

Question 16

what are features of brown-sequard syndrome ?

Answer 16

paralysis on affected side - corticospinal
loss of proprioception and fine discrimination - dorsal columns
pain and temperature loss on opposite side below lesion - spinothalamic

Question 17

what is the acute management of SCI ?

Answer 17

prevent secondary insult
particularly in patients with incomplete injury
ATLS management
surgical fixation

Question 18

what is ATLS management ?

Answer 18

airways + C spine brace
breathing - ventilation with O2, manage chest injury
circulation - fluids, consider neurogenic shock (low BP and HR, loss of sympathetic, vasopressors)

Question 19

what is spinal shock ?

Answer 19

transient depression of cord function below level of injury
flaccid paralysis
areflexia
lasts several hours to days after injury

Question 20

what is neurogenic shock ?

Answer 20

hypotension
bradycardia
hypothermia
injuries above T6
secondary to disruption of sympathetic outflow

Question 21

what investigations should you do for SCI ?

Answer 21

X rays
CT
MRI - neurological deficit or children

Question 22

what is long term management for SCI ?

Answer 22

spinal cord injury unit
physiotherapy
OT
psychological support
urological/sexual counselling

Question 23

what are the different parts of an intervertebral disc ?

Answer 23

annulus fibrosus - tough outer layer

nucleus pulposus - gelatinous core

Question 24

what happens to the intervertebral discs as you age ?

Answer 24

decreased water content
disc space narrows
degenerative changes on X-rays
degenerative changes in facet joints
aggravated by smoking

Question 25

what are features of nerve root pain ?

Answer 25

fairly common
limb pain worse than back pain
pain in a nerve root distribution
root tension signs
root compression signs
dermatomes and myotomes

Question 26

what is the management for nerve root pain ?

Answer 26

most settle, 90% in 3 months
physio
strong analgesia
referral after 12 weeks
MRI

Question 27

what are the different types of disc problems ?

Answer 27

bulge - common, majority asymptomatic
protrusion - annulus weakened but still intact
extrusion - through annulus but in continuity
sequestration - desecrated disc material free in canal

Question 28

what is the most common level for a cervical disc prolapse ?

Answer 28

C5/6

Question 29

what is the most common level for a thoracic disc prolapse ?

Answer 29

T11/12
lower levels
<1% of prolapses

Question 30

what is the most common level for a lumbar disc prolapse ?

Answer 30

L4/5 45%, L5/S1 40%

most posterolateral

Question 31

what is the sensory/motor/reflex change for L5/S1 (S1) disc prolapse ?

Answer 31

sensory - little toe, plantar foot
motor - planter flexion
reflex - ankle jerk

Question 32

what is the sensory/motor/reflex change for L4/L5 (L5) disc prolapse ?

Answer 32

sensory - great toe, first dorsal web space
motor - EHL
no reflex

Question 33

what is the sensory/motor/reflex change for L3/L4 (L4) disc prolapse ?

Answer 33

sensory - medial aspect of lower leg
motor - quad
reflex - knee jerk

Question 34

what is caudal equine syndrome ?

Answer 34

compression of caudal equina
sacral nerve roots compressed
surgical emergency
can result in permanent bladder and anal sphincter dysfunction

Question 35

what is the management of caudal equina syndrome ?

Answer 35

admission
urgent MRI
operation within 48 hours

Question 36

what is the aetiology of caudal equina syndrome ?

Answer 36

central lumbar disc prolapse
tumours
trauma/spinal stenosis
infection - epidural abscess
iatrogenic

Question 37

what are the clinical features of cauda equina syndrome ?

Answer 37

injury or precipitating event
location of symptoms - bilateral buttock + leg pain, varying dysaethesiae + weakness
bowel or bladder dysfunction - urinary retention +/- incontinence overflow
PR exam - saddle anaesthesia, loss of anal tone and anal reflex

Question 38

what are the outcomes for cauda equina syndrome ?

Answer 38

30% undergoing discectomy did not regain normal urinary function
25% with motor deficit never regain full power
33% with sensory deficit never regain normal sensation
25% with perianal paraesthesia did not return to normal
26% had sexual dysfunction

Question 39

what is cervical and lumber spondylosis ?

Answer 39

common condition
degenerative change at facet joints, discs, ligaments
if severe can compress full cord

Question 40

what are features of spinal claudication ?

Answer 40

usually bilateral in legs and back
sensory dysaesthesia
possibly weakness - drop foot
takes several minutes to ease after stopping walking
worse walking down hill as spinal canal smaller, better uphill and bikes

Question 41

what are the different types of spinal stenosis ?

Answer 41

lateral recess stenosis
central stenosis
foramina stenosis

Question 42

what is the treatment for lateral recess stenosis ?

Answer 42

non-operative
nerve root injection
epidural injection
surgery

Question 43

what is treatment for central stenosis ?

Answer 43

non-operative
epidural steroid injection
surgery

Question 44

what is the treatment for foramina stenosis ?

Answer 44

non-operative
nerve root injection
epidural injection
surgery