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.
