spinal orthopaedics Flashcards by Scott Chalmers

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

ends as conus medlars

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what are the different upper limbs myotomes ?

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

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what are the lower limb myotomes ?

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

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

15%

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what is the most common cause of spinal cord injury ?

fall 41.7%

RTA 36.8 %
sport 11.6%

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what constitutes a complete spinal cord injury ?

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

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what is the grading system for SCI ?

ASIA classification

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what are the different grades of the ASIA classification ?

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

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what is tetraplegia (quadriplegia) ?

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

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

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what is spasticity ?

increased muscle tone
UMN lesion
spinal cord and above >L1

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what is paraplegia ?

partial or total loss of use of the lower limbs

loss of motor/sensory in thoracic, lumbar or sacral

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who gets central cord syndromes ?

older patients - arthritic neck
hyperextension injury
most common type

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what are features of central cord syndrome ?

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

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what is the mechanism of injury for anterior cord syndrome ?

hyeprflexion injury
anterior compression fracture
damaged anterior spinal artery

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what are features of anterior cord syndrome ?

profound weakness
fine touch and proprioception preserved
poor prognosis

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what are features of brown-sequard syndrome ?

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

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what is the acute management of SCI ?

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

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what is ATLS management ?

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

what is spinal shock ?

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

what is neurogenic shock ?

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

what investigations should you do for SCI ?

X rays
CT
MRI - neurological deficit or children

what is long term management for SCI ?

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

what are the different parts of an intervertebral disc ?

annulus fibrosus - tough outer layer

nucleus pulposus - gelatinous core

what happens to the intervertebral discs as you age ?

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

what are features of nerve root pain ?

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

what is the management for nerve root pain ?

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

what are the different types of disc problems ?

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

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

C5/6

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

T11/12 lower levels <1% of prolapses

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

L4/5 45%, L5/S1 40% | most posterolateral

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

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

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

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

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

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

what is caudal equine syndrome ?

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

what is the management of caudal equina syndrome ?

admission urgent MRI operation within 48 hours

what is the aetiology of caudal equina syndrome ?

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

what are the clinical features of cauda equina syndrome ?

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

what are the outcomes for cauda equina syndrome ?

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

what is cervical and lumber spondylosis ?

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

what are features of spinal claudication ?

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

what are the different types of spinal stenosis ?

lateral recess stenosis central stenosis foramina stenosis

what is the treatment for lateral recess stenosis ?

non-operative nerve root injection epidural injection surgery

what is treatment for central stenosis ?

non-operative epidural steroid injection surgery

what is the treatment for foramina stenosis ?

non-operative nerve root injection epidural injection surgery