Spinal Symposium Flashcards
outline some elements of a single vertebrae…
vertebral body – WB surface, spinal formamen – conating the cord and later the spinal nerve roots, posterior elements, lamina superior and inferior articular procsess, Pedicles, spinous prcess and trasverese prcoess- allow muscle attachments
think about lordosis and kyphosis, which is which?
lordosis=), kyphosis = (. Thoracic is mainly kyphotic, cervical and lumbar are mainly lordotic (L=L)
what is the erector spinae?
long group of muscles composed of iliocostalism longismius and spinalis
where dos the spinal cord end and what is this called?
L1 - conus medularis
what is a dermatome?
A dermatome is an area of skin that is mainly supplied by a single spinal nerve
What is a myotome?
A myotome is the group of muscles that a single spinal nerve innervates
point outthe dermatomes of the arm on yourself…
clavicle=c4, lateral upper arm = c5, lateral forearm/thumb and index finger = c6, middle finger=c7, ring and pinky= c8, medial forearm = t1
point outthe dermatomes of the leg on yourself…
front goes down from L1 to L5, where L4 covers the majority of the leg and knee, L3 and L2 groin as well, L5 majority of the dorsal foot. Back mainly s1 and s2, L5 is the heel, s1-s5 gets closer to the anus.
what are the Myotomes for the upper limbs?
C5 - Shoulder abduction (deltoid), C 6 - Elbow flexion/ Wrist extensors (biceps), C 7 - Elbow extensors (triceps), C 8 - Long finger flexors (FDS/FDP), T 1 - Finger abduction (interossei)
what are the myotomes for the lower limbs?
L2 - Hip flexion (iliopsoas), L3,4 - Knee extension (quadriceps), L4 - Ankle dorsiflexion (tib ant), L5 - Big toe extension (EHL), S1 - Ankle plantar flexion (gastroc)
look at this card for myotomes and reflexes…..
what is found on examination of complete spinal cord injury?
no motor or sensory function distal to lesion, no anal squeeze, no sacral sensation, ASIA Grade A, no chance of recovery
what is found on examination of incomplete spinal cord injury?
some function left, more favourable prognosis
what scale/classification is used to grade spinal injury on examination?
ASIA Classification
give 5 patterns of spinal cord injury
tetraplegia, paraplegia, central cord syndrome, anterior cord syndrome, brown sequard syndrome.
What is Quadra/Tetraplegia?
Partial or total loss of use of all four limbs and the trunk, Loss of motor/sensory function in cervical segments of the spinal cord.
what are the consequences of tetraplegia when there is a cervical fracture?
Respiratory failure due to loss of innervation of the diaphragm, Phrenic nerve C3-5, ‘C5 keeps you alive’, Spasticity
what is spasticity and when does it occur?
increased muscle tone, UMN lesion, spinal cord and above (CNS), injuries above L1
what is Paraplegeia?
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, Arm function spared, Possible impairment of function in trunk,
consequences of thorcic/lumb fractures leading to Paraplegia?
Associated chest or abdominal Injuries, Spasticity if injury of spinal cord (i.e. above L1), Bladder/ Bowel function affected
outline Central cord syndromes?
Older patients (arthritic neck), Hyperextension injury, Centrally cervical tracts more involved, Weakness of arms, still power in legs so can walk, Perianal sensation & lower extremity power persevered
outline anterior cord syndrome?
Hyperflexion injury, Anterior compression fracture, Damaged anterior spinal artery, Fine touch and proprioception preserved, Profound weakness, poor prognosis of recovery
Brown-sequard syndrome…
Hemi-section of the cord, Penetrating injuries, 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)
How are spinal cord injuries Managed?
Prevent secondary insult ABCD with ATLS measures (advanced trauma life support) airway (control c spine), breathing (vent, o2), circulation (hp, hr, ivfluids, vasopressors), Disability (neurological function, PR, perianal sensation, log rolling), Imaging (xrays, ct, MRI)
what is classified as neurogenic shock?
Hypotension, Bradycardia, Hypothermia, Injuries above T6, Secondary to disruption of sympathetic outflow
what is classified as spinal shock?
Transient depression of cord function below level of injury, Flaccid paralysis, Areflexia, Last several hours to days after injury
after mx with surgical fixation what is the Long-term mx?
Physiotherapy, Occupational therapy, Psychological support, Urological /Sexual counseling
outline the anatomy of iv discs (type of joint, annulus fibrosus, nucleus pulposus)
Secondary Cartilaginous Joint, Disc is largest avascular structure in the body Annulus fibrosus - Tough outer layer/ Nucleus pulposus - Gelatinous core consisting mainly of water, collagen and proteoglycans, Annulus may tear and nucleus prolapse, Can cause cord / nerve root compression Cartilaginous end plate of each disc attaches to bony endplate of vertebra The ALL and PLL connect discs with vertebral bodies The fibres of the annulus fibrosis (collagen) run obliquely and alternately between layers - They resist rotational movements = Discs fail with twisting movements
what direction do disc prolapses occur in usually?
postero-laterally
what is the normal aging process of ivdiscs?
decreased water content, disc spaxce narrowing, degenerative cvhanges on xray and in the facet joint. Aggrevated by smoking etc.
pathological processes on the ivdiscs…
Tearing of annulus fibrosis and protrusion of the nucleus, Nerve root compression by osteophytes, Central spinal stenosis Abnormal movement - Spondylolysis - Spondylolisthesis
what are the types of disc problems?
bulge (generalised - common, asymptomatic), protrusion (annulus still intact but weak), extrusion (through the annulus but in continuity), sequestration (dessicated disc material free in the canal)
what is the most common site of cervical prolapse?
c5/c6
what is the most common site of thoracic prolapse?
t11/t12 - central, posterolateral and lateral herniations
what is the most common site of lumbar prolapse?
l4/l5, l5/s1 - posterolateral, central disc may give pain in both legs or may be back pain only
what motor, sensory and reflex change does l5/s1 cause?
sensory loss of little toe and sole of foot, motor weakness of plantar flexion of the foot, change in ankle jerk reflex
what motor, sensory and reflex change does l4/l5 cause?
sensory loss of great toe and 1st dorsal webspace, motor weakness of EHL
what motor, sensory and reflex change does l3/l4 cause?
sensory loss of medial apect of lower leg, motor loss of quads, change in knee jerk reflex
outline cauda equina syndrome cause…
central lumbar disc prolapse/tumour/ trauma/ infection/ iatrogenic causes compression, surgical emergency, sacral nerve roots compressed – can result in permanent bladder and anal sphincter dysfunction and incontinence
sy/sx 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
what is spondylosis (OA)?
degenerative change at facet joints, discs, ligaments, if severe it can compress the whole cord not just the nerve roots causing myelopathy (UMN signs in limbs - increased tone, brisk reflexes)
name the ligaments of the spine
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
what are the features of spinal 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 and their tx…
Lateral recess stenosis - nerve root injection, epidural, surgery, central stenosis - same, foraminal stenosis - same
CASE 1…
56f, neck pain, 6 months of worsening numbness in the hand, Difficulty doing buttons, Wide based gait. Do a hx and exam, could be cervical myelopathy.
CASE 2…
A 70 year old man presents with a “tired feeling” in both thighs which is precipitated by walking and relieved by rest. He has a long history of backache. Ddx - spinal stenosis, peripheral vascular disease, tell the difference between the two by risk factor assessment and distribution, examine pulses
CASE 3…
A 70 year old lady presents with severe, worsening thoracic and lumbar back pain over several moths. No history of trauma, pain worse on standing but still present when lying in bed at night. History of weight loss. Important diagnosis to include are infection (discitis) or metastatic malignancy to the spine.
