Spinal symposium Flashcards
State whether the cervical, thoracic and lumbar spine have kyphosis or lordosis
c and L = lordosis
T = kyphosis
|n what plane is the spine straight?
coronal
If the spine is not straight in coronal what does this mean?
scoliosis
3 erector spinae muscles
illiocostalis
longissimus
spinalis
Epidemiology of spinal cord injuries
1000/year in UK with most being male
20-29 years
50 000 in UK with paralysis
Causes of spinal cord injuries
falls - RTA - tumour - infection - sport
Complete SCI
no motor or sensory function distal to lesion
no anal squeeze, sacral sensation or chance of recovery
What ASIA grade is complete SCI?
A
Incomplete SCI
some function present below site of injury
more favourable prognosis
Why may you not be able to determine acutely if it is incomplete or complete SCI?
spinal shock
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
Quadriplegia/tetraplegia
partial or total loss of use of all 4 limbs and trunk
loss of motor/sensory function in cervical region
What happens in tetraplegia
cervical fracture - phrenic nerve (diaphragm)
resp failure and spasticity
spasticity in tetraplegia
increased muscle tone
UMN lesion - spinal cord and above
lesions above L1
Paraplegia
partial or total loss of use of lower limbs
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
aetiology of paraplegia
thoracic or lumbar fractures
associated chest or abdominal injuries
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
anterior cord syndrome - briefly describe
hyperflexion injury, anterior compression fracture
injured anterior spinal artery
anterior cord syndrome symptoms
profound weakness
fine touch and proprioception preserved
Causes of Brown-Sequard syndrome
penetrating injuries eg gunshot/stab wound
What is Brown-Sequard syndrome?
hemi-section of cord
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
Managing SCI - broad
prevent 2 insult
ABCD
ATLS
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
