Spine

Question 1

A 61 year old male complained of pain in both buttocks and legs on exercise, relieved by rest.
What are the two diagnoses the history can be typical of?

Answer 1

• Spinal cord stenosis

- Abdominal aortic occlusion/ severe stenosis

Question 2

What is spinal cord stenosis?

What is seen on MRI in spinal cord stenosis?

Answer 2

Central canal stenosis, commonly occurring at an intervertebral disk level, defines midline sagittal spinal canal diameter narrowing that may elicit neurogenic claudication (NC) or pain in the buttock, thigh, or leg.

Multilevel degenerative disc disease with

1. disc protrusions,
2. ligamentum flavum hypertrophy and
3. facet joint degeneration

Abnormalities of the disk usually do not cause symptoms of central stenosis in a normal-sized canal. In developmentally small canals, however, a prominent bulge or small herniation can cause symptomatic central stenosis. Large disk herniations can compress the dural sac and compromise its nerves, particularly at the more cephalad lumbar levels where the dural sac contains more nerves.

Question 3

What is the pathophys of pain in lumbar cord stenosis, and therefore what action relieves the pain?

Answer 3

Patients with significant lumbar spinal canal narrowing report pain, weakness, numbness in the legs while walking, or a combination thereof. Onset of symptoms during ambulation is believed to be caused by increased metabolic demands of compressed nerve roots that have become ischemic due to stenosis. This is the hallmark of neurogenic claudication. The pain is relieved when the patient flexes the spine by, for example, leaning on shopping carts or sitting. Flexion increases canal size by stretching the protruding ligamentum flavum, reduction of the overriding laminae and facets, and enlargement of the foramina. This relieves the pressure on the exiting nerve roots and, thus, decreases the pain. The most common nerve affected is the L5, with associated weakness of extensor hallucis longus.

Question 4

Eighty year old male patient presents with a history of several months of neck pain, bilateral hand and leg weakness. Clinical examination revealed bilateral extensor plantar reflexes. Ddx? (4)

Answer 4

Quadriparesis localizes the neurology to the cervical spine/cord. Possible aetiologies include:

Cervical myelopathy – spinal cord dysfunction commonly secondary to degenerative disease of the cervical spine in the older population (cervical spinal cord stenosis)

Neoplasia eg metastatic disease with cord compression or primary cord neoplasm

Spinal cord infarction/ischaemia

Spinal cord demyelination (uncommon first presentation in the elderly population)

Question 5

What is the best imaging modality for the cervical spine/cord/nerve roots?

Answer 5

MRI

Question 6

A sixty-five year male presents with two weeks of increasing lower back pain and fevers. On examination, there is lower lumbar spine tenderness but no focal neurological signs. Blood tests reveal an elevated ESR and CRP.
What diagnoses would you consider?

Answer 6

• Discitis/ osteomyelitis of the lumbar spine
• Inflammatory spondyloarthropathy
• Malignancy: myeloma/ lymphoma/ mets

Question 7

A sixty-five year male presents with two weeks of increasing lower back pain and fevers. On examination, there is lower lumbar spine tenderness but no focal neurological signs. Blood tests reveal an elevated ESR and CRP.
Investigations?

Answer 7

Blood tests including blood cultures and inflammatory markers
CXR and urinalysis to exclude other sources of sepsis
Imaging of the lumbar spine with MRI or CT (if there are contraindications to MRI or MRI is not available)
Plain radiographs may be performed as part of the initial workup but early changes of discitis/osteomyelitis may not be seen for up to 4 weeks when loss of joint space, cortical endplate erosion or ill definition may be seen. Plain films will not show associated complications such as epidural and paravertebral collections. Therefore, a normal X-ray should not be used to exclude the diagnosis of spinal infection.

Question 8

What are the complications of osteomyelitis of the spinal cord?

Answer 8

What are the possible complications of this condition? development of epidural, paravertebral and psoas abscesses
progressive vertebral body collapse and deformity as a result of discitis/infection
neurological compromise if the spinal cord (in the cervical and thoracic spine), thecal sac/cauda equina or nerve roots are compressed