spinal orthopaedics Flashcards
what level does the spinal cord end and what does it become ?
L1
ends as conus medlars
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)
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
what percentage of people with vertebral fracture/dislocation have spinal cord injury ?
15%
what is the most common cause of spinal cord injury ?
fall 41.7%
RTA 36.8 %
sport 11.6%
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
what is the grading system for SCI ?
ASIA classification
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
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
what is spasticity ?
increased muscle tone
UMN lesion
spinal cord and above >L1
what is paraplegia ?
partial or total loss of use of the lower limbs
loss of motor/sensory in thoracic, lumbar or sacral
who gets central cord syndromes ?
older patients - arthritic neck
hyperextension injury
most common type
what are features of central cord syndrome ?
centrally cervical tracts more involved
weakness of arms > legs
perianal sensation and lower extremity power preserved
what is the mechanism of injury for anterior cord syndrome ?
hyeprflexion injury
anterior compression fracture
damaged anterior spinal artery
what are features of anterior cord syndrome ?
profound weakness
fine touch and proprioception preserved
poor prognosis
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
what is the acute management of SCI ?
prevent secondary insult
particularly in patients with incomplete injury
ATLS management
surgical fixation
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
