Spine Flashcards
what are the lines on lateral spine x ray
- anterior vertebral
- posterior vertebral
- spinolaminar
- posterior spinous
what is the normal prevertebral space measurements
<6mm at C2 (above trachea)
<22mm or 1 vertebral body at C6 (below trachea)
How to localise nerve in radiculopathy
Sensory distribution of pain - dermatomal
distribution of tingling and numbness
motor weakness - myotome
screening - squat and rise (L4), heel walking (L5), toe walking (S1)
reflexes - knee jerk, ankle jerk
Clinical exam findings in scoliosis
Adam forward bend test
- imbalance in height of shoulders
- asymmetrical limb waist distance
- prominence of hips
- truncal shift (plum line from C7 spinous process)
- tilting of shoulder and pelvis
- limb shortening
Causes of radiculopathy
- PID
- spondylosis
- spondylolisthesis
Spondylosis findings on x ray
- narrowing of neural foramen
- facet joint hypertrophy/ arthritis - bony spurs, syndesmophyte
- degeneration of intervertebral disc (loss height, bulge)
- thickening of ligamentum flavum (calcification)
- end plate sclerosis
causes of myelopathy
Degenerative changes
1. degenerative cervical spondylosis
>anterior: protruding disc, posterior syndesmophyte, osteophytes
>anterolateral: jts of luschka
> lateral: cervical facet thickening/ bony spurs
> posterior: ligamentum flavum, spondylolisthesis
2. ossification of posterior longitudinal ligament (OPLL)
3. cervical kyphosis
4. prolapsed intervertebral disc
VITAMINC
- infection (epidural abscess), trauma, tumor, demyelinating disorders, vascular disease, autoimmune (RA)
mgx of myelopathy
Conservative: - analgesia, collar, physio, gait training Canal widening/ surgical decompression - laminectomy, disectomy Fusion if instability present
Mgx of spinal stenosis
education on spine posture
sx:
- wide laminectomy (decompression)
- segmental fusion (for spinal instability)
Causes of cauda equina syndrome
central PID infection - abscess neoplasm - tumor, lymphoma vascular - spinal epidural hematoma, spinal anaesthesia, IVC thrombosis Trauma
Presentation of cauda equina
- saddle anesthesia
- bowel, bladder dysfunction
- bilateral LL weakness
- radiating pain
- low back pain and tenderness
Mgx of cauda equina
and potential cx if tx delayed
Surgical cx within 48 hours
- residual weakness
- permanent urinary/ bowel incontinence
- impotence
- sensory abnormalities
PID pathology
- extents of herniation
acute posterior or postero-lateral herniation of nucleus pulpous through annulus fibrosis
bulge > extrusion > protrusion > sequestration
Central vs posterolateral vs foraminal prolapse
Central
- only back pain
- without leg pain
- bilateral radiculopathy (if prolapse significant)
- beware cauda equina
Postero-lateral:
- most common
- compress transversing nerve root (i.e. L5 in L4/5)
Foramina
- rare
- compress exitting nerve root (i.e L4 in L4/5)
Cervical vs lumbar PID
for both posterolateral herniation:
- EXITTING cervical nerve root
- TRANSVERSING lumbar root
for both, lower level affected
signs for PID on examination
- listing (to relieve pain from nerve compression)
- paravertebral muscle spasm
- protective scoliosis
- loss of lumbar lordosis
- midline tenderness
- pain worse on flexion, decreased ROM
- SLR positive
- segmental myotomal and dermatomal deficits
Mgx of PID
REST: + physio and analgesia and NSAIDs REDUCE: traction SX: removal + rehab for: cauda equina, failure of conservative tx - discectomy
Causes of spondylolisthesis
SPOTED
- Spodylolytic: break in pars interarticularis
- Pathological: neoplasm or infection (TB)
- Operative: laminectomy for decompression
- Trauma
- Elderly: OA (spondylosis)
- Dysplasia: congenital lumbosacral facet joint dysplasia
Classification of spondylolisthesis
Meyerding classification - % translation of VB I: 0-25% II: 25-50% III: 50-75% IV: 75-100%
Mgx of spondylolisthesis
Conservative: bed rest and supportive corset
Operastive: spinal fusion (TLIF: transforaminal lumbar interbody fusion)
Why does spondylosis cause radiculopathy
- loss of disc height
- syndesmophyte
- facet joint hypertrophy
Why does spondylosis cause spinal stenosis
- facet hypertrophy
- thickening of ligamentum flavum
- bulging of degenerate disc
- spur formation
- listhesis
Mgx of spondylolysis
Conservative
- activity modification: weight loss, stop bending, lifting, climbing
- physio
- intermittent traction
- collar
- analgesia
SX
- anterior disc removal with fusion of most painful level
Types of scoliosis
Postural
Structural
- Idiopathic :
- adolescent thoracic (>10)
- infantile thoracic (<4) - Osteopathic: due to congenital vertebral anomalies (hemivertebrae, wedge vertebra, block vertebrae)
- Neuropathic
- Myopathic: in rare muscular dystrophies, spinal muscular atrophy
- Syndromic: Ehler danlos, marfan, NF, VACTERL
Impt history for idiopathic scoliosis
- menarche
- family hx
- when it start
- severity and progression
- previous x rays and treatment
- associated symptoms (back pain, neurological symptoms, clumsiness/ weakness, bladder/ bowel function)
What is the Risser sign grading and its significance
Extent of ossification and fusion of iliac apophysis of pelvis
- suggests skeletal maturity and provides indication for curve progression
0 - premenarchal
1/2 - pubertal
3/4/5 - post pubertal
Grade I: 25% II: 50% III: 75% (passed peak of growth spurt) IV: 100% V: iliac apophysis fused to iliac crest
What is the management of scoliosis
Dependent on cobb’s angle
<20deg: 4mthly observation with full length spine x ray
20-40deg:
- 0/1/2: brace therapy
- 3/4/5: observation
>40deg: - 0/1/2: sx + post op support >50deg: - 3/4/5: sx 50% correction regarded as satisfactory
How to measure Cobb angle
lines projected from uppermost and lowermost vertebral bodies in the curve
Types of kyphosis
Postural Structural - elderly: degenerative - Ankylosing spondylitis - trauma - TB spondylitis - Adolescents: scheurmann disease
Deficit in brown sequard syndrome
Ipsilateral
- LCS: motor
- Dorsal: vibration, propioception
Contralateral:
- pain, temperature
(spinothalamic tracts cross at spinal cord level)
What is Denis 3 column theory
- what are the columns
Ant column: anterior longit lig, ant annulus, ant 2/3 vert body
Mid column: pos 1/3 vert body, post longit lig
Pos column: posterior elements (pedicles, facets, lamina, spinous process), pos ligaments
1 column: stable
2 column: +/-
3 column: unstable
What is a
- compression #/ wedge
- burst #
- chance #
Compression: anterior stress failure (tumour, infx, osteoporotic)
Burst: both ant and mid column (trauma)
- neuro involvement is common (retropulsion of fragments into spinal canal)
- increase in interpedicular distance
Chance: all 3 columns affected
- neuro damage uncommon
- unstable
-
What is ASIA impairment scale
A: complete: no motor and sensory
B: incomplete: no motor, sensory preserved
C: incomplete: some motor (< grade 3)
D: incomplete: some motor (> grade 3)
E: motor and sensory normal
How to differentiate complete vs incomplete spinal cord injury
complete: no fx below lvl of injury (neuro deficit persists after spinal shock ends)
incomplete: some degree of function retained (SACRAL SPARING: perianal sensation, sphincter tone, big toe flexion)
Cervical spine management in trauma after radiological Ix
if film neg, remove collar and complete exam
- palate from occiput to T1
- any tenderness, swelling, step off
- if symptomatic: replace collar
- if neg - do active ROM (should be full and pain free) > C spine clear
- if ROM unable but rest is clear: replace collar and x ray in 2w (flexion-extension views)
NOT reliable if patient is obtunded, other distracting injury
What is a whiplash injury
- s/s
- x ray findings
- mgx
Sprained neck: hyeprflexion/ extension of neck > soft tissue sprain
- pain and stiffness appear 12-48 hours after injury
- x ray normal
- mgx: analgesia, physio
Mgx of compression injury
mild: bed rest + physio
marked wedging: thoracolumbar brace
else
posterior spinal fusion
Spinal shock
- what is it
- when it ends?
- how to test?
complete spinal areflexia
physiological dysfunction of spinal cord (complete paralysis and anaesthesia, loss of anal reflex) - loss of basal excitatory stimulus from brain to neurons
- flaccid areflexic paralysis
- bradycardia and hypotension
- absent bulbocav reflex
bulb-cavernous reflex - signifies end
- monitor anal sphincter contraction in response to squeezing the glans penis/ clitoris
General management of spine injuries
if incomplete transection: emergency surgical decompression and stabilisation of spine
acute mgx
reduction: acute closed reduction with axial traction
if no sx, bracing and observation
rehab
general:
- skin: prevent pressure sores
- bladder: catheterise, bladder training subsequently
- bowel: enemas, abdominal exercises
- muscles, joints - prevent contractors: physio
- reversing contractures: tenotomy
- DVT prophylaxis
- cardiopulmonary mgx
Complication of spinal cord injuries
- skin problems (ulcers)
- venous thromboembolism
- urosepsis
- sinus bradycardia
- orthostatic hypotension (no sympathetic tone)
- autonomic dysreflexia (by unchecked visceral stimulation): headache, agitation, HTN
- MDD
features of central cord syndrome
MUD
motor more than sensory
upper limb > LL
distal > proximal
ddx of radiculopathy
thoracic outlet syndrome
carpal tunnel syndrome or ulnar nerve entrapment
rotator cuff lesions
cervical tumor
what are the causes of lumbar stenosis
- degenerative changes from spondylosis (facet joint hypertrophy, syndesmophytes)
- spondylolisthesis
- space occupying lesions - abscess, infections
- trauma
- inflammatory: ankylosing spondylitis, RA
