Spinal symposium Flashcards by Jade Kiersten

State whether the cervical, thoracic and lumbar spine have kyphosis or lordosis

c and L = lordosis

T = kyphosis

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|n what plane is the spine straight?

coronal

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If the spine is not straight in coronal what does this mean?

scoliosis

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3 erector spinae muscles

illiocostalis
longissimus
spinalis

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Epidemiology of spinal cord injuries

1000/year in UK with most being male
20-29 years
50 000 in UK with paralysis

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Causes of spinal cord injuries

falls - RTA - tumour - infection - sport

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Complete SCI

no motor or sensory function distal to lesion

no anal squeeze, sacral sensation or chance of recovery

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What ASIA grade is complete SCI?

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Incomplete SCI

some function present below site of injury

more favourable prognosis

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Why may you not be able to determine acutely if it is incomplete or complete SCI?

spinal shock

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ASIA grade and description

A- complete, no sensory or motor in S4-5
B- incomplete, no motor in S4-5
C- incomplete, motor below level - muscles <3 power
D - incomplete, motor below level - muscles >3
E- normal sensory and motor

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Quadriplegia/tetraplegia

partial or total loss of use of all 4 limbs and trunk

loss of motor/sensory function in cervical region

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What happens in tetraplegia

cervical fracture - phrenic nerve (diaphragm)

resp failure and spasticity

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spasticity in tetraplegia

increased muscle tone
UMN lesion - spinal cord and above
lesions above L1

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Paraplegia

partial or total loss of use of lower limbs

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Symptoms of paraplegia

impairment or loss of sensory/motor in T/L/S
arm function spared
possible impairment in trunk 
bladder/bowel function 
spasticity in spinal cord injured

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aetiology of paraplegia

thoracic or lumbar fractures

associated chest or abdominal injuries

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Central cord syndrome - briefly describe

older patients eg arthritic neck, hyperextension injury
arm>leg weakness, perianal sensation and lower extremity power preserved
low velocity fall

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anterior cord syndrome - briefly describe

hyperflexion injury, anterior compression fracture

injured anterior spinal artery

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anterior cord syndrome symptoms

profound weakness

fine touch and proprioception preserved

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Causes of Brown-Sequard syndrome

penetrating injuries eg gunshot/stab wound

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What is Brown-Sequard syndrome?

hemi-section of cord

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symptoms in Brown-Sequard syndrome and tracts affected

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

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Managing SCI - broad

prevent 2 insult
ABCD
ATLS

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ABCD - explain

A - c spine control B - ventilation, O2, associated chest injury C - IV fluids, neurogenic shock? low BP and HR, vasopressors D - neurological function, PR and perianal, log roll

Spinal shock

transient depression of cord function below injury level flaccid paralysis and areflexia several hours --> days

neurogenic shock

hypotension and bradycardia hypothermia injuries above T6 - 2 to sympathetic outflow disruption

imaging in SCI

x-ray CT - bone MRI - neurological defecit or child

Surgical fixation in SCI

unstable fractures | from posterior aspect - pedicle screws

Long term management of SCI

physio/OT spinal cord injury unit psychological, sexual and urological counselling

Lumbar disc prolapse - lateral and central

lateral - compressed nerve root | central - compressed roots within cauda equina

intervertebral discs joint type

secondary cartilaginous

What is the largest avascular structure in the body?

intervertebral disc

2 components of intervertebral disc

tough outer layer = annulus fibrosus | gelatinous core = nucleus pulposus

injuries to annulus fibrosus and nucleus pulposus

AF - may tear and NP prolapse

What ligaments attach discs to vertebral bodies?

ALL and PLL

Significance of collagen orientation inn AN. Fib,

run obliquely - resist rotational movements

what makes up the nucleus pulposus?

80% water, collagen and proteoglycans

What direction are disc prolapses usually?

postero-lateral

Normal ageing process of discs

lower water content, disc space narrowing and degenerative changes in facet aggravated by smoking etc

Pathological process of discs

tear AN.F and prolapse N.P osteophytes compress nerve roots central spinal stenosis abnormal movements eg spondylosis/spondylolisthesis

Nerve root pain

fairly common - limb pain worse than back pain | pain in nerve root distribution

Managing nerve root pain

90% settle in 3 months physio and strong analgesia refer after 12 weeks --> MRI

disc problems - bulge

common, asymptomatic?

disc problem - protrusion

annulus weakened but still intact

disc problem - extrusion

through annulus but in continuity

disc problem - sequestration

dessicated disc material free in canal

cervical disc prolapse

C5/6

Thoracic disc prolapse

<1% | most in T11/12

Lumbar disc prolapse

L4/5 then L5/S1 then L3/4

Why are most lumbar disc prolapses posterolateral?

PLL is weakest

Prolapsed disc - give nerve root, sensory loss, motor weakness and reflex change A - L5/S1 B - L4/5 C - L3/4

A - S1, little toe and sole of foot, plantarflex - ankle jerk B - L5, great toe and 1st web space, EHL C - L4, medial aspect of lower leg, quads, knee jerk

Managing cauda equina syndrome

SURGICAL EMERGENCY | admission, urgent MRI and op in 48 hrs

What can be the result of sacral nerve compression?

permanent bladder and anal sphincter dysfunction and incontinence

Aetiology of cauda equina syndrome

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

Clinical features of cauda equina syndrome

injury or precipitating event locate symptoms - bilat buttock and leg pain, dysaesthesia and weakness badder or bowel dysfunction - overflow incontinence PR exam - saddle anaesthesia, loss of anal tone and reflex

Who should you have a high index of suspicion for cauda equina syndrome?

spinal post op with leg pain and urinary retention

Radiography in cauda equina syndrome

MRI (if CI use lumbar CT myelogram)

Cervical and lumbar spondylosis

common, degenerative change at facet, disc, ligament | if severe can compress whole cord causing myelopathy

Facet joint type and what movements are allowed

true synovial - flex and extension

What movements do discs allow?

between vertebrae

5 ligaments related to vertebral column

``` ALL PLL Ligamentum flavum interspinous and supraspinous intratransverse ```

Lumbar spondylosis

OA of facet and disc joints

Spinal claudication

``` bilateral sensory dysaesthesia weakness? several mins to ease worse walking downhill ```

Treatment for lateral recess stenosis and foraminal stenosis

non-op nerve root injection epidural surgery

treating central stenosis

non op epidural steroid injection surgery

treating spondylolisthesis

conservative | surgery if persistent root pain or nerve root entrapment