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Ortho ST3 Interview > Spine > Flashcards

Spine Flashcards

1
Q

How to clear a c spine in a trauma patient?

A

CT scan -ve is key in an unconcious patient

O/E no pain/tenderness
No neurology
Assess all movements of the c spine

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2
Q

What are spinal precautions in a trauma patient?

A

Blocks and collar
Log rolling
Hospital bed
Full lower limb neuro +ASIA monitoring
Saddle anaesthetesia + Anal tone

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3
Q

What are differentials for a patient with a spinal injury and decreased urine output?

A

Pre renal/ intrinsic/post renal causes
Cauda Equina
Shock- hypovolaemic/neuological
Pain
Urological trauma

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4
Q

What makes up the intervertebral disc?

A

Soft centre- neucleus propulsus
Firm outer ring- annulus fiborsis

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5
Q

Parts of the a vertebral body?

A

https://upload.wikimedia.org/wikipedia/commons/thumb/7/7c/Vertebra_Superior_View-en.svg/1200px-Vertebra_Superior_View-en.svg.png

Remember Lamina and pedicles
Pedicles lateral boarder of vertebral canal

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6
Q

What are the spinal column ligaments?

A

5 in total
Ant Longitudinal Lig
Post LL (Runs along post boarder of vertebral body
Lig Flavum- post aspect of spinal canal
Interspinous- connects spinous process bodies
Supraspinous lig- connects tips of spinous processes

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7
Q

What comprises the Posterior Ligament complex? And how do you assess if its damaged?

A

LF
SL
IL
Facet capsule

Use MRI to assess

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8
Q

What categories makes of the Thoracolumbar Injuy classification and severity score?

A

Morphoology of fracture:
Compression, burst, rotational, distraction

Neurology:
Intact, nerve root/complete cord, incomplete cord/cauda equina

PLC integrity- Intact, suspected, injured

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9
Q

How to manage spinal thoracolumbar fractures?

A

If TLICS <4 then non op
If >4 operative
If 4 then surgeon dependent

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10
Q

What is the cauda equina and what is CES?

A

Cauda equina is a collection of peripheral nerves that run in the verterbral canal beyond the end of the spinal cord from L2-S5

Because they are not surrounded by the spinal cord they are more at sensitive to compression and damage.

CES is the collection of signs and symptoms related to compression of the cauda equina

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11
Q

What are the causes of CES?

A

Disc herniation- commonest cause
Spinal epidural haematoma
Spinal cord tumour
Spinal epidural abscess
Trauma (retropulsion/dislocation/collapse)
Spondylothesis- slipping of vertebral bodies

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12
Q

What are theGIRFT syptoms and then red flags for CES?

A

GIRFT National guidelines- published in 2023

Recent onset within 2 weeks
Any bilateral sciatica +- Back pain
Bilateral paralysis/parasthetsia
Saddle Anaesthetsia
Difficult micturating/impaired sensation of flow
Loss of sensation of rectal fullness
Incontinence
Erectile dysfunction/loss of genitalia sensation

Associated red flags
Fever
Wt Loss
Night sweats
IVDU
Cancer
Previous spinal surgery
Immunosuppression

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13
Q

What is the thinking around PVRs in CES?

A

Not diagnostic nor can it exclude CES

Woodfield et al. 2023
60% of patients undergoing decompression for CES had a PVR of <200mls

A PVR of >200mls increases likelihood of CES by 20 times

If >600mls PVR then catheterise + tug test

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14
Q

How do you examine a patient with ?CES

A

Full lower limb neuro exam
Expose
Tone
Power- sharp vs blunt, proprioception
Reflexes
Coordination

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15
Q

Key investigation and urgency for CES?

A

Lavy et al. found a 43% false positive rate for the diagnosis of CES

MRI is gold standard for diagnosis
To be ordered within 1-2 hours of ED presentation
To be done within 4 hours of request

GIRFT

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16
Q

How do you classify Cauda Equina?

A

Lavy et al.

  1. CES Suspected (CESS): Patients are at risk of developing CES. There is bilateral sciatica or motor/sensory changes in the lower limbs but no sphincteric or perineal sensory changes. Includes anyone at risk of developing CES, e.g. due to a large disc.
  2. CES Incomplete (CESI): The above with one of altered bladder/bowel fnx, saddle anaesthesia, sexual dsyfnx (ejactulatory, erection, sensation)
  3. CES with retention (CESR): In addition to CESI, there is painless bladder retention
    and overflow.
  4. CES Complete (CESC): Insensate bladder with overflow incontinence, no perineal, perianal or sexual sensation, and no anal tone.
17
Q

What is the management of CES + outcomes?

A

If confirmed on MRI requires urgent decompression

Catheterise and tug as needed
Analgesia
Bloods + 2xG&S
Consent and mark

Contact anaesthetist/CEPOD/consultant on call/transfer to spinal centre

Ahn et al. 2000 Optimum theatre time within 48 hours of symptoms starting for best outcomes

Operation dependent on aetiology- microdiscectomy vs laminectomy vs haematoma/abscess evacuation

18
Q

How long can the recovery period of symptoms be from CES?

A

Motor 1 year
Bladder 16 months

19
Q

Indication for CT c spine in trauma?

A

Within 1 hour:

GCS<13/intubated
abnormal plain films
Polytrauma
Clinical suspicion + >65/dangerous MOI (fall from >1m/5 stairs) + focal neurology

20
Q

Indications for CT head?

A

Within 1 hour:
GCS <13 on initial assessment
GCS <15 after 2 hours of injury
Post traumatic seizures
Open or depressed skull fracture
Signs of basal skull fracture
Focal neurology
More than one discrete episode of vomiting

Within 8 hours if LOC or amnesia:

+>65 years
Bleeding/clotting issues
>30 mins of retrograde amnesia

21
Q

Name some different types of incomplete spinal cord injury?

A

Central cord syndrome- Upper limbs worse than lower limbs, motor worse than sensory, elderly hyperextension type injury

Ant cord syndrome-Paralysis LL worse than UL, preserved prioprioception, loss of pain/temperature

Brown sequard- hemicord injury, BLT, ContraL loss of pain/temp, IpsiL loss of power/prioprioception

22
Q

What is a complete spinal cord injury

A

Paraplegia and complete loss of sensation/prioprioception below injury

23
Q

What is a Pars Defect?

A

Fracture through facet joint
Can lead to spondylolithesis

24
Q

What is spondylolithesis?

A

Displacement of spinal vertebra compared to another
L5 is commonest
Due to trauma, dsyplasia, malignany and iatrogenic

25
Q

What is disc herniation?
What is the commonest direction and level?

A

When the inner neucleus propulsus herniates through a weaken annular fibrosis
Tends to occur posterolateral due to strong longitudinal ligament

95% is L4/5 and L5/S1

L5/S1 is commonest

26
Q

Which nerve root will a herniating disc affect?

A

It depends:
In paracentral or lateral herniation, the transversing nerve root is usually affected; a lateral herniation at L4-L5 would cause L5 radiculopathy. Extreme lateral (far lateral) herniations typically result in the exiting nerve root being affected; extreme lateral herniation at L4-L5 would cause L4 radiculopathy.

https://upload.orthobullets.com/topic/2035/images/illustration%20cervical%20v%203s.jpg

27
Q

What is the spinal cord blood supply?

A

Ant and Post spinal arteries
Ant 2/3 from anterior spinal artery formed from vertebral arteries

Post 1/3 from post inf cerebral arteries off vertebral artery

28
Q

Describe the upper and lower limb dermatomes

A

C5: lateral aspect of arm
C6: lateral aspect of forearm and hand
C7: middle finger and ray
C8: medial aspect of hand
T1: medial aspect of forearm

L1: Inguinal
L2: Lateral thigh
L3: Medial knee
L4: Medial malleolus
L5: dorsum over 3rd MCT
S1: Lateral Calcaneum
S2: Popliteal fossa
S3: Gleuteal crease
S4/5: Perianal area

29
Q

What are the limb myotomes?

A

C4: shoulder shrugs
C5: elbow flexion
C6: wrist extension
C7: elbow extension and wrist flexion
C8: finger flexion
T1: finger abduction
L2: hip flexion
L3: knee extension
L4: ankle dorsiflexion
L5: big toe extension
S1: ankle plantarflexion
S4: bladder and rectum motor supply

30
Q

What the important points in consenting a patient for cauda equina decompression?

A

Surgery is attempting to prevent further deterioration of neurology. There is a risk bladder/bowel symptoms may not improve or take a long time to improve.
Complications: nerve root
injury, dural leak or spinal cord injury; recurrence of my problem; fibrous tissue formation; infection
and skin and nerve pressure problems. GA and medical problems- infections/clots.
Rare but serious complications: death, paralysis, eye
complications including blindness, serious vascular injury, stroke

31
Q

How to manage hypercalcaemia?

A

A2E
IVT
ECG
Bisphosphonates?
Local guidelines
Medics

32
Q

How to manage Metastatic spinal cord compression?

A

MSCC- coordinator
16mg oral dexamathasone
(if no spinal cord compression- consider in patients with haem cancer/severe pain)
MRI as soon as possible- within 24 hours
MDT approach
Radiotherapy vs surgical decompression + stabilisation + adjuvant radiotherapy

33
Q

Spiel for cauda equina approach?

A

Concerned about cauda equina syndrome.
Triple assessment including history, full lower limb neuro exam + PR + ASIA chart, investigations- Post void bladder scan and MRI
Analgesia

34
Q

Spinal trauma spiel?

A

Concerns about head injury and spinal cord injury- management as per BOAST for traumatic spinal cord injury.

ATLS protocol- primary survey identifying any life or limb threatening injury including triple immobilisation of the C spine, log rolling the patient + PR examination.

AMPLE

Full upper and lower limb neuro exam
ASIA chart
Urgent discussion with tertiary spinal centre

35
Q

Difference between spinal and neurogenic shock?

A

Neurogenic is loss of sympathetic tone to heart due to injury above T6- Low HR + Low BP- needs vasopressor support

Spinal shock- complete loss of motor, sensation and autonomic function below level of injury due to spinal cord injury

36
Q

What must happen before invasive intervention for MSCC?

A

MDT discussion with oncologists, spinal specialists

37
Q

Difference between cervical radiculopathy and myelopathy?

A

Radiculopathy is compression of nerve root leading to LMN symptoms

Myelopathy is spinal cord narrowing causing UMN and LMN signs

38
Q

Why do hoffmans test?

A

Snapping flexion of middle finger distal phalanx

+ve if thumb flexion and adduction

Cervical UMN pathology

39
Q

Difference between LMN and UMN lesion?

A

LMN- reduced tone, reduced power, areflexia,fasciulations

UMN - increased tone, hyperreflexia, upgoing babinski’s/positive hoffman’s, clonus

Ortho ST3 Interview (12 decks)

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