Spine

Question 1

what is a radiculopathy

Answer 1

conduction block in the axons of a spinal nerve or its roots

with impact on motor axons causing weakness and on sensory axons causing paraesthesia and/or anaesthesia

Question 2

radiculopathy vs radicular pain

Answer 2

radiculopathy is a state of neurological loss and may or may not be associated with radicular pain

radicular pain is pain deriving from damage or irritation of the spinal nerve tissue, particularly the dorsal root ganglion

Question 3

what is most commonly the cause of radiculopathy

Answer 3

nerve compression

Question 4

what are some common causes of spinal nerve compression

Answer 4

intervertebral disc prolapse

degenerative diseases of the spine leading to stenosis

fracture

malignancy - most commonly metastatic

infection e.g. osteomyelitis or herpes zoster

Question 5

in any spinal injury what is it key to rule out and how do you do this

Answer 5

cauda equina syndrome

assessing perinanal sensation, anocutaneous reflex, anal tone and rectal pressure sensation

Question 6

common clinical features of radiculopathy

Answer 6

sensory weakness - paraesthesia and numbness

motor weakness

often radicular pain is also present

Question 7

Red flag symptoms in any case of radiculopathy and what associated disorder they indicate

Answer 7

faecal incontinence, urinary retention and saddle anaesthesia = Cauda equina syndrome

immunosuppression, IV drug use and unexplained fever = infection

chronic steroid use = fracture or infection

significant trauma, osteoporosis or bone disease = fracture

new onset after 50 yrs old = malignancy

history of malignancy = metastatic disease

Question 8

management of radiculopathy

Answer 8

surgical - the only condition that requires surgical treatment is cauda equina syndrome, most IV disc prolapses can be managed non-operatively

symptomatic management - analgesia and physio, neuropathic pain medication are used aswell

Question 9

examples of neuropathic pain medications

Answer 9

first line = amitryptiline, gabapentin and pregabalin are used as alternatives

Question 10

what is degenerative disc disease

Answer 10

natural deterioration of the intervertebral disc structure, such that they become progressively weak and begin to collapse

often related to aging

Question 11

what are the pathophysiological changes seen in degenerative disc disease

Answer 11

dysfunction - outer tears of the annulus fibrosus and cartilage destruction

instability - disc resorption and loss of disc space height, along with capsular laxity can lead to subluxation and spondylolisthesis

restabilisation - degenerative changes lead to osteophyte formation and canal stenosis

Question 12

clinical features of degenerative disc disease

Answer 12

depends on region and severity

early stage is localised - local spinal tenderness, contracted paraspinal muscles, hypomobility or painful extension of the back or neck

when it progresses to cause instability, the pain may become more severe and include radicular leg pain or paraesthesia

Question 13

what is Lasegue’s test and what does it test for

Answer 13

also known as straight leg raise, used to assess for disc herniation

patient lays down on back, examiner then lifts leg whilst the knee is straight

a positive sign is when pain is elicited during the leg raising

Question 14

what is the gold standard of imaging for degenerative disc disease

Answer 14

MRI spine

Question 15

management of degenerative disc disease

Answer 15

adequate pain relief with simple analgesics as first line followed by neuropathic analgesics as adjuncts if required

encourage mobility and physiotherapy

if pain persists beyond 3 months then referral to pain clinic

Question 16

what are the most common fractured vertebrae in the neck

Answer 16

C2 and C7

Question 17

what is the main classification system for cervical fractures

Answer 17

AO classification system

Question 18

describe a jefferson fracture

Answer 18

burst fracture of the atlas, caused by axial loading of the cervical spine resulting in the occipital condyles being driven into the lateral masses of C1

Question 19

describe a Hangman’s fracture

Answer 19

fracture through the pars interarticularis of C2 bilaterally, usually with subluxation of the C2 vertebrae on C3

caused by cervical hyperextension

Question 20

investigations into cervical fractures

Answer 20

CT scan in adults

MRI in children

Question 21

management of cervical fractures

Answer 21

restricting movement of the spine to prevent potential damage to the spinal cord

non-operative management is appropriate for stable injuries

unstable fractures are treated operatively by fusing the injured segments to the uninjured segments above and below

Question 22

where is the most commonly fractured region in the spine

Answer 22

thoracolumbar junction (T11-L2)

Question 23

describe the classification system used in spinal (thoracolumbar) fractures

Answer 23

AO classification

Type A - compression injuries

Type B - distraction injuries

Type C - translation injuries

Question 24

describe a burst fracture

Answer 24

occurs when there is a substantial compressive force acting through the anterior and middle column of the vertebrae, resulting in retropulsion of bone into the spinal canal

can result in potential spinal cord injury

Question 25

what are chance fractures

Answer 25

vertebral fractures that result from excessive flexion of the spine and involve all three vertebral columns

unstable injuries and often require surgical intervention to stabilise

Question 26

Investigations into spinal fractures

Answer 26

plain film radiograph first

if this is abnormal then perform a CT scan - or with clinical features suggestive of a spinal cord injury

if pathological cause is suspected then perform a myeloma screen and serum calcium