spinal surgery Flashcards
spinal neuroanatomy
Cervical and thoracic central canal Spinal cord Spinal cord terminates at L1. Cervical enlargement c5-T1 Lumbar central canal Lumbosacral nerve roots Lumbar enlargement L2-S3
UMN lesion
LMN lesion
Anupper motor neuronlesionisa lesionoftheneuralpathway above the anterior hornofthe spinal cord ormotornucleiofthe cranial nerves. ALower motor neuronlesionisa lesion which affects nerve fibers traveling from the anterior hornofthe spinal cord to the associated muscle(s).
cervical cord compression
thoracic cord compression
compression of the lumbosacral nerve roots
Cervical cord compression Lesion of the CNS Upper limb involvement (UMN) Lower limb involvement (UMN) Sphincter dysfunction (UMN) Thoracic cord compression Lesion of the CNS Upper limbs are spared Sphincter dysfunction (UMN) Lower limb involvement (UMN) Compression of the lumbosacral nerve roots Lesion of the PNS Lower limb involvement Sphincter Involvement
spinal cord compression
vs
nerve root compression
spinal cord compression Weakness (non myotomal) Sensory loss (non dermatomal) Increased tone Hyperreflexia Clonus Extensor Plantar response(+ve babinksi) \+ve Hoffmans
nerve root compressionWeakness localized to the specific Nerve root.
Sensory loss localized to the specific nerve root
Muscle wasting (localized)
Fasciculations
Hypotonia
Hyporeflexia/ areflexia
Normal plantar response
SCI
Traumatic Atraumatic Spinal Tumours Epidural haematoma Spinal infection Compression related to degenerative narrowing of the central spinal canal Degenerative cervical myelopathy Large posterior disc bulge (Cervical or thoracic spine) Syrinx
nerve root injury
Cauda Equina Syndrome (lumbar spine only)
Radicular pain
Sensory radiculopathy
Motor radiculopathy
primary and secondary role of surgeon
Primary role
Intervene to preserve neurological function
Surgical removal of a spinal tumour
Surgical fixation of a spinal fracture
Secondary role
Intervene to treat disabling nerve root or axial spinal pain related to specific structural pathology
Surgical fixation of a persistently painful osteoporotic fracture
Discectomy for persistently disabling radicular leg pain
time for spinal problems
Persistent spinal cord or nerve root compression can cause irreversible neurological deficits
Small surgical window of opportunity to intervene to preserve neurological function.
Foot drop
Cauda equina syndrome
Spinal cord injuries
It is important to recognize when your patient needs time sensitive care.
Emergency spinal imaging +/- surgical opinion is usually accessed through the Emergency department (ED).
%
90% of patients non specific spinal pain No clear structural cause No specific surgical target 5-10% specific spinal pathology Nerve root symptoms secondary to disc herniation/ spinal stenosis Deformity Scoliosis Degenerative cervical myelopathy Thoracic myelopathy (Calcified thoracic disc protrusion) <1% serious spinal pathology Cauda Equina syndrome Spinal tumour Spinal infection Spinal fracture
role of physio
Identify features suggestive of serious pathology
Recognise when an indication for emergency referral exists
Surgical opinion via the Emergency Department
Identify features suggestive of specific spinal pathology
Recognise when an indication for a spinal surgical referral exists.
spinal pathologies requiring surgical management
Nerve root compression Spinal Cord Compression From the outside (i.e. degenerative stenosis/ vertebral fracture/ vertebral metastasis) From the inside (i.e. syringomyelia) Cauda Equina Compression
cauda equina syndrome
Prevalence 4 in 10,000 ( in CLBP population)
Usually caused by a central disc herniation or a spinal tumour
It is a surgical emergency
Produced by compression of the sacral nerve roots of the cauda equina ( S1-S4)
All patients with acute or deteriorating back (+/- radicular) pain should be assessed for CES in primary/ secondary care.
NB: Explain the context of your questions to the patients to ensure they understand their relevance.
identify
Perianal, perineal or genital sensory loss.
Difficulty initiating micturition (passing urine) or impaired sensation of urinary flow (if untreated this may lead to irreversible urinary retention with overflow urinary incontinence).
Bilateral radicular leg pain.
Severe or progressive neurological deficit of both legs, such as major motor weakness of knee extension, ankle eversion, or foot dorsiflexion.
Loss of sensation of rectal fullness (if left untreated this may lead to irreversible faecal incontinence).
Laxity of the anal sphincter (Does not need to be assessed in primary care)
Erectile dysfunction (Achievement of erection or ability to ejaculate).
CES
explore
Onset and progression of symptoms
Other causes for leg pain
History of bladder/bowel disturbance/ sexual dysfunction
consider
Side effects of pharmacology
Age: Older patients may have spinal stenosis and are less likely to have acute CES.
Functional symptoms: psychosocial presentation and prior healthcare utilization.
presentations - increase prob of acute / threatened CES
Presence of new SA/ Bladder or bowel disturbance
Age < 50
Radicular pain
Unilateral radicular pain progressing to bilateral
Sudden onset bilateral radicular leg pain
Alternating radicular leg pain
Presence of new motor weakness
Obesity
Previous CES
Congenitally narrow spinal canal
presentations not managed with emergency spinal surgery
Urinary or bowel disturbance that has been present for more than 4 weeks and is not deteriorating.
Let the ED/surgeon make that decision
Should still be referred as an emergency
Older people with symptomatic spinal stenosis in the absence of acute bladder disturbance.
prognosis of CES
If symptoms are suggestive of CES: immediately referral to the ED should be made.
If you suspect a patient may be at risk of developing CES
Communicate clearly what the person should do if symptoms develop or progress.
NB: This must be documented.
nerve root compression
Cervical/ thoracic spine Single site of compression at each level Exit foramen Lumbar spine 2 potential sites of compression at each level Lateral recess Exit foramen
nerve root symptoms
Axial spinal pain +/- limb pain in a dermatomal distribution
+/- sensory disturbance in a dermatomal distribution
+/- muscle weakness in the muscle groups innervated by the specific nerve root (myotomal).
LBP+/- leg pain (not necessarily in a specific dermatomal distribution)
Aggravated with walking/ standing
Eased with sitting or forward bending.
+/- Symptoms of nerve compression
Sensory disturbance
Motor weakness
Sphincter disturbance
natural history of nerve root symptoms
Rate of resolution (Weber et al 1993, Vroomen et al 2000)
50% recovered at 2/52
60% recovered at 3/12
70% recovered at 12/12
Advanced imaging is only indicated when a patient fails to respond to a reasonable algorithm of conservative care (minimum 6 weeks)
Pain medication
Limiting activities or positions which aggravate nerve root symptoms
Rehabilitation
Timing of rehabilitation is important
features concerning for serious pathology
Presence of features concerning for serious pathology Infection Fracture Cancer Bleed Myelopathy CES
factors to consider
Age Disc versus stenosis Dominant symptom Axial spine pain Limb pain Distribution of peripheral symptoms Dermatomal Non- dermatomal Unilateral or bilateral SIN Severity Irritability Nature Extent of neurology Grade of weakness Correlates with specific nerve root Functional impact Baseline level of physical activity Duration of symptoms Stability of symptoms Response to treatment to date Pharmacy Conservative Treatment Imaging findings* MRI findings which correlate with the distribution of symptoms and signs. Timing of imaging Patient preference
onward referral
Radicular leg pain with significant neurological deficit (MRC >4/5) but no concerning features for serious underlying pathology
Urgent MRI
Correlating pathology – surgical referral
Radicular leg pain with major motor radiculopathy(<3/5)/ Suspected serious pathology/ Severe unrelenting radicular leg pain unresponsive to pain medication.
Emergency Department
Radicular pain/ normal neurology/ no features concerning for serious pathology
Conservative management
Radicular pain <6/52 + mild stable neurological deficit/ no features concerning for serious pathology
Isolated diminished or absent reflex/ dermatomal sensory deficit or motor deficit which does not impact on function (EHL weakness/ some difficulty with SLHR but normal gait, mild triceps weakness)
Conservative management
Radicular pain > 6/52 with severe pain and functional deficit / not resolving
Link in with GP regarding referral for advanced imaging
Correlating pathology on imaging – surgical referral
patient with axial LBP who may benefit from spina surgical opinion
Young athlete/ dancer (sport involves hyperextension) who develops LBP
Disabling LBP+/- nerve root symptoms and imaging evidence of pars defect +/- spondylolisthesis.
Adult spinal deformity
Persistent disabling LBP which has not responded to exhaustive conservative treatment.
Claudicant LBP with imaging evidence of high grade stenosis
cervical myelopathy
Describes any neurologic deficit related to the spinal cord. Usually caused due to cord compression by osteophyte or extruded disc material. Examples of other causes Spinal tumour Trauma Inflammatory or autoimmune disease Cervical epidural abscess Vascular pathologies Arteriovenous malformation Epidural haematoma
degen cervical myelopathy
Serious and specific spinal pathology
Most common type of spinal cord injury
Delayed diagnosis and treatment results in an Irreversible spinal cord injury
Surgery is very effective treatment but recovery is typically incomplete
Should always be included in your differential diagnosis of a patient presenting with neck pain/ upper limb sensory disturbance/ hand function disturbance / gait disturbance.
Delayed diagnosis is very common
presentation of myelopathy
Age
> 40
Often between 50-70 but can begin in elderly
Neck and arm pain (unilateral or bilateral).
Neck stiffness
Gait disturbance (Degeneration of corticospinal tract)
Sensory disturbance in one or both arms or hands
Hand function disturbance
Clumsiness and dexterity loss (interneuronal loss)
Grip Strength weakness (Atrophy of the anterior horns associated with motor neuronal loss)
Urgency of bladder more than bowels, Urinary urge incontinence and urinary frequency
typical neurological findings
Hyperreflexia Localised Global Long tract signs Increased tone Upgoing plantar response Sustained clonus \+ve Hoffmans Non dermatomal sensory loss Non myotomal weakness Gait disturbance Spastic gait
diagnosis
Diagnosis 1 symptom of DCM 1 neurological sign (UMN) MRI evidence of cord compression Management Severity of myelopathy (mJOA) Moderate/ severe : Urgent surgical decompression Mild Surveillance Surgery Prophylactic surgery not recommended in asymptomatic compression
assessment of patients with spinal pain
Understanding what pathologies have the potential to cause cord and nerve root compression and how they typically present. Metastatic spinal cord compression Age History of cancer Unexplained weight loss Progressively worsening spinal pain Thoracic pain
symptoms suggestive of neurological dysfunction
Listening for symptoms suggestive of neurological dysfunction . Pins and needles/ Numbness Weakness/heaviness in limbs Hand function disturbance (Cervical) Difficulty walking Sphincter disturbance Bilateral symptoms Radicular pain
taking a comprehensive neuro exam
Knowledge of dermatomes/ myotomes.
Differentiate between Cord compression and nerve root compression
emergency referral
Suspected Cauda Equina Syndrome Suspected spinal cord compression Related to serious underlying pathology Tumour Infection Bleed Fracture Progressive Significant neurological dysfunction Major motor radiculopathy Suspected new spinal fracture Trauma Atraumatic Osteoporotic Pathological
urgent referral
Suspected spinal cord compression
Moderate/ severe degenerative cervical myelopathy
Severe unrelenting radicular leg pain not responsive to usual pain medication
Suspected new pars defect in adolescent or young adult
routine
Radicular pain Sensory radiculopathy Mild stable motor radiculopathy Mild stable degenerative cervical myelopathy Axial spinal pain Imaging evidence of specific structural abnormality Deformity Pars defect (spondylolsis) High grade IVD disease
Persistent disabling axial spinal pain not responding to a reasonable algorithm of conservative care.
