Spine

Question 1

What is cervical spondylosis?

Answer 1

Degenerative disease of the cervical spine

Neck/shoulder pain/stiffness, headaches often starting at back of neck

Includes cervical radiculopathy and cervical spondylotic myelopathy?

Question 2

What is cervical radiculopathy?

Ix / Tx?

Answer 2

Pinched nerve - cervical root compression secondary to lateral disc prolapse or osteophytes

Brachialgia (referred arm pain from nerve root irritation)

Ix: MRI cervical spine, CT can show foraminal stenosis

Tx: conservative initially, surgery for significant motor deficit, persistent brachialgia after conservative measures and rarely uncontrolled brachialgia

Question 3

What would C4/C5 disc prolapse cause?

Answer 3

C5 nerve root compression

Pain from side of neck - shoulder, numbness over deltoid

Deltoid weakness

Diminished bicep reflex

Sensory disturbance to shoulder and arm

Question 4

What would C5/C6 disc prolapse cause?

Answer 4

C6 root compression

Pain over lateral arm and forearm, sensory disturbance in lateral forearm thumb and index finger

Weak biceps and brachioradialis

Diminished biceps and supinator reflex

Question 5

What would C6/C7 disc prolapse cause?

Answer 5

C7 root compression

Pain radiating down middle forearm to middle and sometimes ring finger, sensory disturbance of middle finger

Weakness - elbow, wrist and finger extensors

Diminished tricep reflex

Question 6

What would C7/T1 disc prolapse cause?

Answer 6

C8 root compression

Pain radiating to medial forearm and hand, sensory disturbance to medial border hand / ring / little finger

Weakness of hand grip / intrinsic muscles

Question 7

What is cervical spondylotic myelopathy?

Answer 7

Numb, clumsy hands with difficulty of fine manipulation

Unsteady gait due to pyramidal signs (spasticity and bilateral extensor plantars) and sensory ataxia

Bladder symptoms in more advanced disease

Natural history unclear but disability from cervical spinal cord compression probably develops early

Ix: MRI cervical spine (CT cervical spine may also be useful)

Tx: surgery if progressive myelopathy or stable myelopathy to prevent further deterioration - aim to prevent further neurological deterioration as existing deficit may not improve

Question 8

What is lumbar spondylosis

Answer 8

Degenerative disease of lumbar spine

May include cauda equina syndrome, compressive lumbar radiculopathy?

Question 9

What is cauda equina syndrome

Answer 9

Commonly central lumbar disc prolapse requiring urgent surgical intervention. Rarely, non-compressive causes e.g. viral infection, inflammatory condition

Symptoms: bilateral leg pain or sensory disturbances, perianal, perineal and ‘saddle’ anaesthesia, urinary and/or faecal incontinence, lower back pain, significant bilateral motor deficit, sexual dysfunction

Investigation: MRI lumbar/sacral spine

Tx: urgent neurosurgical decompression

Question 10

What is compressive lumbar radiculopathy?

Answer 10

95% of lumbar intervertebral disc prolapses are at L5/S1 or L4/L5. Presents with sciatic pain (shooting, linear, radicular pain through buttock or hip down leg - commonly below knee often but not always with mechanical lower back pain

If L5 radiculopathy - sensory disturbance in antero-lateral calf and dorsum of foot with weakness of extensor hallucis longus (EHL) and ankle dorsiflexion

If S1 radiculopathy - sensory disturbance in sole of foot and back of calf, weakness of ankle plantar flexion and absent ankle reflex

Ix: MRI lumbar spine or CT myelography

Tx: conservative, bed rest then early mobilisation, analgesia, avoidance of lifting, muscle relaxants, referral for epidural / nerve root block. Surgery if cauda equina, significant motor deficit, severe pain, failure of conservative management

Question 11

What is thoracic interverebral disc prolapse?

Answer 11

Rare to have symptomatic disc prolapse <1% of all protruded discs, most common level T11/12 with 75% of all prolapses below T8

Thoracic back pain, often nocturnal, recumbent

Parapesis with sensory level (may see Brown-Sequard pattern in rare cases)

Bladder and bowel control problems

Ix: MRI thoracic spine

Tx: surgical intervention for patients with myelopathy or sphincter dysfunction

Question 12

How are spinal tumours classified?

Answer 12

Extradural: metastases, multiple myeloma, lymphoma

Intradural extramedullary: meningioma, scwannoma, metastases

Intramedullary: ependyoma, astrocytoma, metastases

Question 13

Most common spinal tumour?

Answer 13

Metastatic disease: common primary carcinomas include lung breast prostate renal and thyroid

Often present with localised pain before the onset of symptoms related to the spinal cord compression

Palpation of spine usually produces local tenderness

Myelopathy, radiculopathy, sensory symptoms and impaired bladder control develop as a consequence of spinal cord / nerve root compression or vascular compromise

Question 14

Management of spinal metastatic disease?

Answer 14

High dose dexamethasone
Radiotherapy if sensitive
Surgical decompression if neurological dysfunction is severe / rapidly progressive in suitable candidates

Question 15

What is syringomyelia?

Answer 15

Cystic cavitation of spinal cord

Causes: Chiari type I malformation (most common - 25% will have syringomyelia), post-trauma, spinal neoplasm, arachnioditis

Dissociated sensory loss (i.e. loss of pain/temp, preserved vibration/proprioception), wasting of small muscles of hands, Charcot joints (painless arthropathies)

Tx: Normal flow of CSF e.g. by foramen magnum decompression in syrinx associated with Chiari type I malformation

Question 16

Outline the main causes of spinal cord disease?

Answer 16

Inherited: hereditary spastic paraparesis, Friedreich’s ataxia, adrenomyeloneuropathy

Developmental disorders (neural tube defects)

Mass lesion

Inflammation: MS, isolated acute transverse myelitis, neurosarcoidosis, Devic’s disease (neuromyelitis optica)

Infection: viral (HIV, HTLV-1, herpes), bacterial (syphilis, brucellosis, borreliosis), parasitic (schistosomiasis)

Vascular: anterior spinal artery occlusion, dural AV fistula

Metabolic: vitamin B12 deficiency

Question 17

Spinal trauma / fractures

Answer 17

Add in info

Question 18

How is spinal cord injury graded?

Answer 18

ASIA

A - complete lack of motor and sensory function below the level of injury (3% walk again in 18 months)
B- some sensation below (sacral sensation) (50%)
C - 50% muscles power <3/5 (75%)
D - >50% power >3/5 (95%)
E - intact (100%)

Question 19

What is Brown-Sequard?

Answer 19

Rare: hemi-section of cord

Ipsilateral motor and proprioception loss, contralateral pain and temperature loss

Good prognosis

Question 20

What is a central cord lesion?

Answer 20

Common, hyperextension especially in elderly after flexion / extension injury with underlying stenosis

Bilateral motor and sensory deficit, arms worse than legs

Good prognosis

Question 21

What is an anterior cord lesion?

Answer 21

Ischaemia (2/3 blood supply from anterior spinal artery) - loss of motor, pain and temperature but preserved proprioception

Poor prognosis

Question 22

What is a posterior cord lesion?

Answer 22

Very rare - B12 deficiency and syphilis

Loss of proprioception only

Question 23

When considering a complete spinal cord injury what factors should be assessed?

Answer 23

Sacral sparing: sacral elements lie peripherally, cord injury tends to be most severe centrally, secral sensation usually last preserved

Anal tone on PR

Bulbo-cavernosus reflex: pressure on glans or clitoris or pull of catheter causes contraction of anal sphincter, less subjective

Priapism: likely to be complete injury, useful in intubated patients

Question 24

What is spinal shock?

Answer 24

Misleading term (not true shock like neurogenic shock)

Refers to observation that reflex activity sometimes stops following spinal injury for about 24 hours, accounts for the flaccid paralysis associated with spinal injury, makes it impossible to assess if injury is truly complete in the acute stages

Question 25

What is neurogenic shock

Answer 25

Inadequate tissue perfusion - mechanism though disruption of sympthetic outflow and therefore vascular tone - arterial dilation - hypoperfusion - warm t touch with bradycardia and hypotension, treat with pressors like noradrenaline (not fluids or inotropes)

Question 26

Treatment of spinal cord lesions?

Complications?

Answer 26

Traditionally steroids but recent NASCET evaluation showe no benefit

Stabilising spine suprisingly controversial - little evidence that improves neurology, more to allow early mobilisation

Complications:

Early: hypotension and bradycardia (SNS), hypoventilation (phrenic), GI bleeding (Cushing’s ulcer’s), ileus

Late: pressure sores, DVT/PE, spasticity, catheterisation, constipation, autonomic dysreflexia (sudden sympathetic over-activity to minor stimulus like urinary retention leading to HTN, bradycardia, sweating, priapism).