Spinal Symposium Flashcards
draw a typical vertebae
see notes
name the articulations of the rib to the vertebae
head of rib to articular facets on vertabrae of number and one above
tubercle of rib to transverse process of same number
name the type of curves in the spine: cervical
lordosis
name the type of curves in the spine: thoracic
kyphosis
name the type of curves in the spine: lumbar
lordosis
myotome: L2
hip flexion - iliopsoas
myotome: L3,4
knee extension - quads
myotome: L4
ankle dorsiflexion - tib ant
myotome: L5
big toe extension EHL
myotome: S1
ankle plantar flexion gastroc
the majority of people with a spinal cord injury will also have what?
accompanying column injury
what is the peak age for spinal cord injuries?
20-29
most common causes of spinal cord injuries
fall RTA sport knocked over trauma sharp trauma/assault
describe the features of a complete spinal cord injury
no motor or sensory function distal to lesion
no anal squeeze
ASIA grade A
no change of recovery
describe the features of an imcomplete spinal cord injury
some function is present below site of injury
more favourable prognosis overall
why may it be difficult to determine acutely the extend of spinal cord injury?
spinal shock
describe grade A ASIS classification
complete
no sensory or motor function preserved in sacral segments S4-5
describe grade B ASIS classification
incomplete
sensory but not motor funciton preserved below the neurologic level and extending through sacral segments S4-5
describe grade C ASIS classification
incomplete
motor function preserved below the neurologic level
majority of key muscle have a grade <3
describe grade D ASIS classification
incomplete
motor function preserved below the neurologic level
majority of key muscle shave a grade > 3
describe grade E ASIS classification
normal motor and sensory funciton
what is tetraplegia?
quadriplegia
partial or total loss of use of all four limbs and the trunk
loss of motor/sensory funciton in cervical segments of the spinal cord
what may cause tetraplegia?
cervical fracture
features of tetraplegia
respiratory failure due to loss of the diaphragm (phrenic nerve C3-5)
spasticity
what is spasticity
increased muscle tone
upper motor neuron lesion
spinal cord and aboce (CNS)
spasticity occurs in injuries above what level?
L1
what is paraplegia
partial or total loss of use of the lower-limbs
impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord
features of paraplegia
arm function spared
possible impairment of function in trunk
possible spasticity
bladder/bowel funciton affected
causes of paraplegia
thoracic/lumbar fractures
associated chest or abdominal injuries
name 3 partial cord syndrome
central cord syndrome
anterior cord syndrome
Brown-Sequard syndrome
who gets central cord syndrome?
older patients with arthritic neck
cause of central cord syndrome?
hyperextension injury
features of central cord syndrome
centrally cervical tracts more involved
weakness or arms>legs
perianal sensation and lower extremity power preserved
causes of anterior cord syndrome
hyperflexion injury
anterior compression fracture
damaged anterior spinal artery
features of anterior cord syndrome
fine touch and proprioception preserved
profound weakness
what is Brown-Sequard Syndrome?
hemi-section of the cord
cause of Brown-Sequard Syndrome
penetrating injuries
features of Brown-Sequard Syndrome
paralysis on affected side (corticospinal)
loss of proprioception and fine discrimination )dorsal columns)
pain and temperature loss on the opposite side below the lesion (spinothalamic)
management of spinal cord injuries
prevent secondary insult esp in those with incomplete
ABCD
ATLS
features of spinal shock
transient depression of cord fucntion below level of injury
flaccid paralysis
areflexia
last several hours to days after injury
features of neurogenic shock
hypotension bradycardia hypothermia injuries above T6 secondary to disruption of sympathetic outflow
long term management of spinal cord injuries
spinal cord injury unit physiotherapy occupational therapy psychological support urological/sexual counselling
what kind of joint is there with IV discs?
secondary cartilaginous
describe the structure of the IV discs
annulus fibrosus - tough outer layer
nucleus pulposus - gelatinous core
what is the largest avascular structure in the body?
IV disc
what causes disc prolapse?
annulus tears and nucleus prolapse
what can a disc prolapse cause?
cord/nerve root compression
in what direction do the fibres of the annulus fibrosis (collagen) run?
obliquely and alternately between layers
what movements to the IV discs prevent?
rotational
what makes up the nucleus pulposus?
water 88%
collagen
proteoglycans
shape of IV disc
Kidney bean
in what direction are most disc prolapses?
postero-lateral
describe the normal ageing process of the spinal column
decreased water content of discs
disc space narrowing
degenerative changes on xrays
degenerative changes in the facet joints
pathological processes occurring in the spinal column
tearing of annulus fibrosis and protrusion of the nucleus
nerve root compression by osteophytes
central spinal stenosis
abnormal movement - spondylolysis, spondylolisthesis
features of nerve root pain
limb pain worse than back
pain in a nerve root distribution (radicular)
root tension signs
root compression signs
treatment of nerve root pain
most will settle, 90% in 3 months physio strong analgesia referral after 12 weeks imaging - MRI
name the 4 common disc problems
bulge
protrusion
extrusion
sequestration
draw and describe IV disc problems: bulge
generalised
common
majority asymptomatic
?relevance
draw and describe IV disc problems: protrusion
annulus weakened but still intact
draw and describe IV disc problems: extrusion
through annulus but in continuity
draw and describe IV disc problems: sequestration
dessicated disc material free in canal
most common site of cervical disc prolapse
C5/6
most common site of thoracic disc prolapse
mid to lower levels T8-12
most common T11/12
most common site of lumbar disc prolapse
usually L4/5 - 45%
L5/S1 - 40%
L3/4 - 10%
least common site of disc prolapse?
thoracic - 1%
directions of thoracic disc prolapse
central, posterolateral and lateral herniations
directions of lumbar disc prolapse
posterolateral
nerve root affected in prolapse: L5/S1
S1
nerve root affected in prolapse: L4/5
L5
nerve root affected in prolapse: L3/4
L4
sensory loss in disc prolapse: L5/S1
little toe
sole of foot
sensory loss in disc prolapse: L4/5
great toes
1st dorsal web space
sensory loss in disc prolapse: L3/4
medial aspect of lower leg
motor weakness in disc prolapse: L5/S1
plantar flexion foot
motor weakness in disc prolapse: L4/5
EHL
motor weakness in disc prolapse: L3/4
quads
reflex change in disc prolapse: L5/S1
ankle jerk
reflex change in disc prolapse: L4/5
none
reflex change in disc prolapse: L3/4
knee jerk
what is cauda equina syndrome?
compression of cauda equina
sacral nerve roots compressed - can result in permanent bladder and anal sphincter dysfunction and incontinence
treatment of cauda equina syndrome
surgical emergency
admission, urgent MRI, emergency op within 48h of onset, delay results in permanent dysfunction
causes of cauda equina syndrome
central lumbar disc prolapse tumour trauma - burst or chance # disc spinal stenosis infection - epidural abscess iatrogenic - spinal surgery or manipulation, spinal epidural
clinical features of cauda equina syndrome
– Injury or precipitating event
– Location of symptoms (bilat buttock & leg pain +
varying dysaethesiae + weakness – beware)
– Bowel or bladder dysfunction (urinary retention
+/- incontinence overflow)
– PR exam - saddle anaesthesia (perianal loss of
sensation), loss of anal tone & anal reflex
– High index of suspicion in spinal post-op
patients with increasing leg pain in presence
of urinary retention
outcome of cauda equina syndrome
• 30% undergoing discectomy for cauda equina
syndrome did NOT regain normal urinary function
• 25% with motor deficits never regained full power
• 33% with sensory deficits never regained normal
sensation
• 25% with perianal paraesthesiae did not return to
normal
• 26% had persitent sexual dysfunction
cervical and lumbar spondylosis results from degenerative change where?
facet joints
discs
ligaments
if cervical and lumbar spondylosis is severe what can it cause?
compression of whole cord causing myelopathy
UMN signs in limbs
what movements are there in the lumbar spine?
flexion and extension
name the ligaments of the spinal column and where they are found
• Anterior Longitudinal Ligament (ALL – along the
front of the vertebral bodies – broad, strong)
• Posterior Longitudinal Ligament (PLL – along the
backs of the vertebral bodies, i.e. front of the spinal canal;
narrower)
• Ligamentum Flavum (between laminae)
• Interspinous and Supraspinous Ligaments
(between spinous processes)
• Intertransverse Ligament (between transverse
processes)
how can you distinguish spinal claudication from vascular claudication
– Usually bilateral – Sensory dysaesthesiae – Poss weakness (drop foot – tripping) – Takes several minutes to ease after stopping walking – Worse walking down hills because the spinal canal becomes smaller in extension, better walking uphill or riding bicycle
types of spinal stenosis
lateral recess stenosis
central stenosis
foraminal stenosis
treatment of lateral recess stenosis
non-op
nerve root injection
epidural injection
surgery
treatment of central stenosis
non-op
epidural steroid injection
surgery
treatment of foraminal stenosis
non-op
nerve root injection
epidural injection
surgery
treatment of spondylolisthesis
Treatment depends on symptoms
• Conservative with lifestyle changes
• Surgery for persistent pain +/- nerve root
entrapment
