Spine and Upper Limb (Dundee bones) Flashcards
Mechanical back pain
This can be thought of as recurrent relapsing and remitting back pain with no neurological symptoms. The pain is worse with movement (mechanical) and relieved by rest. Patients tend to be between the age of 20 and 60 and have had several previous “flare‐ups”. No “red flag” symptoms are present.
Causes implicated include obesity, poor posture, poor lifting technique, lack of physical activity, depression, degenerative disc prolapse, facet joint OA and spondylosis. Spondylosis is where the intervertebral discs lose water content with age resulting in less cushioning and increased pressure on the facet joints leading to secondary OA.
What is spondylosis
Spondylosis is where the intervertebral discs lose water content with age resulting in less cushioning and increased pressure on the facet joints leading to secondary OA.
Treatment for mechanical pain
Analgesia and physiotherapy
Is bed rest advised in mechanical pain?
Bed rest is not advised as this will lead to stiffness and spasm of the back which may exacerbated disability.
What is instability? (back)
excessive motion caused by a degenerate disc
Acute disc tear (discogenic back pain)
An acute tear can occur in the outer annulus fibrosis of an intervertebral disc which classically happens after lifting a heavy object (eg lawnmower). The periphery of the disc is richly innervated and pain can be severe.
Pain is characteristically worse on coughing (which increases disc pressure).
Symptoms usually resolve but can take 2‐3 months to settle.
Analgesia and physiotherapy are the mainstay of treatment.
When is disc tear pain worse?
Coughing
When might you tear a disc?
Typically on lifting a heavy object, e.g. lawnmower
Pain is severe
How long does it take a disc tear to heal?
2-3 months
Sciatica symptoms
The radicular pain is felt as a neuralgic burning or severe tingling pain, often like severe toothache radiating down the back of the thigh to below the knee. (Note back pain can radiate to the buttock and thigh but not below the knee)
Constant pain in only one side of the buttock or leg (rarely can occur in both legs)
Pain that is worse when sitting
Burning or tingling down the leg (vs. a dull ache)
Weakness, numbness or difficulty moving the leg or foot
A sharp pain that may make it difficult to stand up or to walk
Test used to assist diagnosis of sciatica
perform sciatic stretch test - dorsiflex foot at this point of discomfort - test is positive if additional pain results
L3/L4 entrapment
L3/4 prolapse > L4 root entrapment > pain down to medial ankle (L4), loss of quadriceps power, reduced knee jerk
L4/L5 entrapment
L4/5 prolapse > L5 root entrapment > pain down dorsum of foot, reduced power Extensor Hallucis Longus and tibialis anterior
L5/S1 entrapment
L5/S1 prolapse > S1 root entrapment > pain to sole of foot, reduced power planarflexion, reduced ankle jerks
Bony nerve root entrapment
OA of the facet joints can result in osteophytes impinging on exiting nerve roots, resulting in nerve root symptoms and sciatica.
Surgical decompression, with trimming of the impinging osteophytes, may be performed in suitable candidates.
Why is spondylosis different to PVD (peripheral vascular disease?)
the claudication distance is inconsistent
the pain is burning (rather than cramping)
pain is less walking uphill (spine flexion creates more space for the cauda equina)
pedal pulses are preserved
Which nerves are compressed in cauda equina syndrome?
Mainly S4 and S5
Spine and upper limb red flags
- Cauda equina syndrome
- Back pain in the younger patient (60 years)
Back pain in the older patient may represent arthritic change or a crush fracture. However patients in this age group are at higher risk of neoplasia, particularly metastatic disease and multiple myeloma.
- Nature of pain ‐ constant, severe pain, worse at night
Mechanical back pain is worse with activity and tends to be relieved by rest. Pain from tumour or infection tends to be constant, unremitting, severe and worse at night.
- Systemic upset
Fevers, night sweats, weight loss, fatigue and malaise may indicate the presence of underlying tumour or infection.
Any suspicion of underlying infection or tumour requires thorough history and examination with potential investigations including bloods (CRP, FBC, U&Es, bone biochemistry, plasma protein electrophoresis, PSA for males, blood culture if suspecting infection), spine xray (may show vertebral collapse of loss of a pedicle on AP view), chest xray, bone scan and MRI scan.
Symptoms of cauda equina syndrome
Patients usually have bilateral leg pain, paraesthesiae or numbness and complain of “saddle anaesthesia” – numbness around the sitting area and perineum.
Altered urinary function is typically urinary retention but incontinence can also occur. Faecal incontinence and constipation can also occur.
In essence, any patient with bilateral leg symptoms/signs with any suggestion of altered bladder or bowel function is a cauda equina syndrome until proven otherwise.
Cauda equina syndrome
Occasionally a very large central disc prolapse can compress all the nerve roots of the cauda equina producing a clinical picture known as cauda equina syndrome. This is a surgical emergency as affected nerve roots include the sacral nerve roots (mainly S4 & S5 but variable and others contribute) controlling defaecation and urination. Prolonged compression can potentially cause permanent nerve damage requiring colostomy and urinary diversion and urgent discectomy way prevent this catastrophe. Symptoms and signs of cauda equina syndrome are one of the “red flags” of the spine which signify serious underlying pathology requiring urgent management.
Patients usually have bilateral leg pain, paraesthesiae or numbness and complain of “saddle anaesthesia” – numbness around the sitting area and perineum.
Altered urinary function is typically urinary retention but incontinence can also occur. Faecal incontinence and constipation can also occur.
In essence, any patient with bilateral leg symptoms/signs with any suggestion of altered bladder or bowel function is a cauda equina syndrome until proven otherwise.
A rectal examination (PR) is mandatory and it is considered negligent not to perform this is a cauda equine syndrome is missed.
Urgent MRI is required to determine the level of prolapse and urgent discectomy is required once the diagnosis is confirmed. Even with prompt surgical intervention, significant number of patients have residual nerve injury with permanent bladder and bowel dysfunction.
Which examination is mandatory in possible cauda equina syndrome?
Rectal examintation
What do you do if you suspect cauda equina syndrome?
-Rectal examination (OR ELSE)
-Urgent MRI (detect level of prolapse)
-Urgent discectomy once diagnosis is confirmed
(rectal exam->MRI->surgery)
What should you consider diskitis with?
Emedicine says you should consider diskitis with osteomyelitis because they often occur together
Diskitis presenting complaint
Neck or back pain with localized tenderness is the initial presenting complaint. Movement exacerbates these symptoms, which are not alleviated with conservative treatment (eg, analgesics, bed rest).
Osteoma vs osteosarcoma, which one would you rather have?
Osteoma is benign
Osteosarcoma is malignant
What could new back pain in the older patient (>60) suggest?
Back pain in the older patient may represent arthritic change or a crush fracture. However patients in this age group are at higher risk of neoplasia, particularly metastatic disease and multiple myeloma.
What could back pain in the young patient be? (<20)
Significant back pain in childhood, adolescence or early adulthood is uncommon. Younger children are more susceptible to infections (osteomyelitis, discitis) whilst adolescents are the peak age for spondylolisthesis as well as some benign (eg osteoid osteoma) and malignant (eg osteosarcoma) primary bone tumours. Clinicians should have a low index of suspicion for referral or MRI.
Difference between mechanical back pain and pain from infection/tumour?
Mechanical back pain is worse with activity and tends to be relieved by rest. Pain from tumour or infection tends to be constant, unremitting, severe and worse at night.
Which tests should you carry out if suspicious of an infection? (general)
Any suspicion of underlying infection or tumour requires thorough history and examination with potential investigations including bloods (CRP, FBC, U&Es, bone biochemistry, plasma protein electrophoresis, PSA for males, blood culture if suspecting infection), spine xray (may show vertebral collapse of loss of a pedicle on AP view), chest xray, bone scan and MRI scan.
Which condition could a balloon vertebroplasty be used? (Only if you have decided to try something different to conservative treatment)
Osteoporotic crush fracture
Cervical Spondlyosis
As with the rest of the spine, spondylosis can occur with disc degeneration leading to increased loading and accelerated OA of the facet joints. Patients will complain of slow onset stiffness and pain in the neck which can radiate locally to shoulders and the occiput. Physiotherapy and analgesics are the mainstay of treatment.
Osteophytes can also impinge on the exiting nerve roots resulting in a radiculopathy involving the upper limb dermatomes and myotomes which may require decompression for severe symptoms resistant to conservative management.
Cervical disc prolapse
Acute and degenerative disc prolapse can also occur in the cervical spine producing neck pain and potentially nerve root compression.
With nerve root compression, patients complain of shooting neuralgic pain down a dermatomal distribution with weakness and loss of reflexes depending on the nerve root affected. Typically, the lower nerve root is involved (ie C7 root for C6/7 disc, C8 root for C7/T1 disc). A large central prolapse can compress the cord leading to a myelopathy with upper motor neurone symptoms and signs.
Clinical findings and MRI will aid diagnosis of the affected level and again for cases resistant to conservative management, surgery may be considered (discectomy). As with lumbar disc prolapse, the number of patients with asymptomatic disc prolapse increases with age resulting in a higher rate of “false positives” or “incidental findings” on MRI scanning. Clinical findings should correlate with MRI findings before contemplating surgery.
Cervical spine instability and Down syndome
Children with Down syndrome are at risk of developing atlanto‐axial (C1/C2) instability with subluxation potentially causing spinal cord compression. Screening with flexion‐extension xrays will demonstrate the abnormal motion (high atlanto‐dens interval). Children with minor degrees of instability may be prevented from high impact / contact sports. Severe instability or the presence of abnormal neurology may require surgical stabilization.
Upper motor neurone symptoms
wide based gait, weakness, increased tone, upgoing plantar response
How do you investigate cervical spine instability?
flexion‐extension xrays
Causes of shoulder impingement
Tendonitis Subacromial bursitis
Acromioclavicular OA with inferior osteophyte
A hooked acromion Rotator cuff tear
Loss of shoulder external rotation is the principle clinical sign of which condition?
Frozen shoulder/adhesive capsulitis
Which other conditions are associated with frozen shoulder?
Diabetes
Hypercholesterolemia
Dupuytrens
Imaging method of choice for tears in the glenoid labrum?
MRI arthrogram (contrast injected into joint)
What is anterior shoulder pain with pain on resisted biceps contraction. Surgical division of the tendon with or without attachment to the proximal humerus may be required to relieve symptoms. The tendon can spontaneously rupture resulting in relief of symptoms however some are left with a bunched up biceps muscle (“Popeye deformity”)?
Inflammation of the long head of the biceps (biceps tendonitis)
Causes of carpal tunnel syndrome
Although it may be idiopathic (most cases), it can occur secondary to many conditions including rheumatoid arthritis (synovitis > less space) and conditions resulting in fluid retention – pregnancy, diabetes, chronic renal failure, hypothyroidism (myxoedema). Carpal tunnel syndrome can also be a consequence of fractures around the wrist (especially a Colles fracture). With pregnancy the symptoms usually subside after childbirth. Women are affected up to 8 times more than men.
Which type of fracture is associated with carpal tunnel syndrome?
Colles fracture
When is carpal tunnel syndrome pain worse?
At night :(
Which tests reproduce the pain of carpal tunnel syndrome?
Tinnels test
Phalens test
Froment’s test, tests which muscle?
Adductor pollucis
Which muscles may be weak in cubital tunnel syndrome?
First dorsal interosseous
Adductor pollObucis
Osborne’s fascia?
A tight band of fascia that can form on the roof of the cubital tunnel
-May cause cubital tunnel syndrome
Cubital tunnel syndrome
4.2 Cubital tunnel syndrome
This involves compression of the ulnar nerve at the elbow behind the medial epicondyle (”funny bone” area).
Patients complain of paraesthesiae in the ulnar 1½ fingers and Tinel’s test over the cubital tunnel is usually positive. Weakness of ulnar nerve innervated muscles may be present including the 1st dorsal interosseous (abduction index finger) and adductor pollicis. The later can be assessed with Froment’s test.
Compression can be due to a tight band of fascia forming the roof of the tunnel (known as Osborne’s fascia) or due to tightness at the intermuscular septum as the nerve paUlsses through or between the two heads at the origin of flexor carpi ulnaris.
Nerve conduction studies confirm the diagnosis and the patient may need surgical release of any tight structures.
Ulnar innervated muscles of the hand
First dorsal interosseous muscle (index abductor)
Adductor pollucis
What is the humero-ulnar joint responsible for?
Flexion/extension of the elbow
Where does the triceps muscle insert?
The olecranon process
Where does the brachialis insert?
The coranoid process
Where does the biceps insert?
The bicipital process on the radius
Where does the common extensor arise from?
The lateral epicondlye
Where does the common flexor arise from?
The medial epicondyle
OA in elbow?
OA in elbow is rare (if it ever arises, it will probably be secondary due to trauma e.g. intra-articular fracture)
Rheumatoid commonly affects elbow
Lateral epicondylitis?
Tennis elbow
(common extensor arises from the lateral epicondyle)
Tennis players/anyone who regularly performs resisted extension of the wrist
Pathology of lateral epicondylitis
Microtears in the common extensor origin
Lateral epicondylitis clinical features
Clinical features include a painful and tender lateral epicondyle and pain on resisted middle finger and wrist extension.
Treatment for lateral epicondylitis
Treatment involves a period of rest from the activities that exacerbate the pain, physiotherapy, NSAIDs, steroid injections and use of a brace (known as an elbow clasp). Ultrasound therapy is also used but its efficacy is unclear.
Rarely, refractory cases may be offered surgical treatment which involves division and/or excision of some fibres of the common extensor origin however has variable results.
Which muscles are responsible for supination of the elbow?
Biceps and supinator muscles
Which muscles are responsible for pronation of the elbow?
Pronator teres and pronator quadratus
Which is more common, tennis elbow or golfers elbow?
Tennis elbow
Why is injection dodgy in medial epicondylitis?
Could damage the ulnar nerve
Surgery for arthritic elbow?
Arthritic change at the radio‐capitellar joint which has failed non-operative management can be treated with surgical excision of the radial head which affords good pain relief with minimal functional limitation.
An elbow severely affected by RA or OA at the humero‐ulnar joint which isn’t satisfactorily treated with conservative management can be treated surgically with a Total Elbow Replacement, which has reasonable long term results. However, lifting in these patients is restricted to 2.5kg postoperatively.
Which nationality is strongly associated with dupuytrens contracture?
Northern european/scandinavian
Which drug can cause dupuytren’s contracture?
hint: its an anti-convulsant
Phenytoin
Hand condition associated with alcoholic cirrhosis?
Dupuytrens contracture
Dupuytren’s can occur with other fibromatosis diseases, name two of these
Peyronie's disease (bent penis) Ledderhose disease (fibromatosis affecting the plantar fascia)
Difference between faciectomy and fasciotomy for dupuytren’s?
Fasciectomy = removing the fascia Fasciotomy = division of the cords
Which pulley is affected in trigger finger?
The A1 pulley
Trigger finger
Tendonitis of a flexor tendon to a digit can result in nodular enlargement of the affected tendon, usually distal to a fascial pulley over the metacarpal neck (the A1 pulley).
Movement of the finger produces a clicking sensation, as this nodule catches on and then passes underneath the pulley. This sensation may be painful and the finger may lock in a flexed position as the nodule passes under the pulley but can’t go back though on extension. The patient may have to forcibly manipulate the finger to regain extension, usually with pain. Any finger can be affected but the middle and ring are those most commonly affected.
In most cases injection of steroid around the tendon within the sheath will relieve symptoms. Surgery can be offered in recurrent and persistent cases. Surgery involves incision of the pulley to allow the tendon to move freely. Due to the system of other pulleys, division of the A1 pulley does not affect function.
Treatment for trigger finger
In most cases injection of steroid around the tendon within the sheath will relieve symptoms. Surgery can be offered in recurrent and persistent cases. Surgery involves incision of the pulley to allow the tendon to move freely. Due to the system of other pulleys, division of the A1 pulley does not affect function.
OA and the MCPs
Rarely OA can affect the metocarpalphalageal (MCPs) joints but there is usually specific cause for this. For example: previous injury, occupational stress, gout or infection. Surgical treatment is possible for arthritis at the MCPs. MCP joint replacements are available which may relieve pain and improve ROM however complications are not uncommon (ulnar drift, extensor tendon subluxation).
OA and the hand
Wear and tear arthritis in the small joints of the hand can be troublesome for patients particularly when performing intricate tasks. 80% of over 60s will have radiological evidence of OA in the hands but only a minority complaining of symptoms.
Distal interphalangeal joints (DIP) OA is very common in postmenopausal women. DIPs will become painful, swollen and tender eventually affecting all fingers. Stiffness and bony thickening can be seen readily on examination (Heberden’s nodes). An associated dorsal ganglion cyst (known as a mucous cyst) may be present. Mild to moderate OA may be treated with removal of osteophytes and excision of any mucous cyst. For severe pain arthrodesis may be performed.
The proximal interphalangeal joint (PIP) can also be affected with OA and bony swelling (Bouchard’s nodes). For the index finger arthrodesis may be required to preserve pinch grip. For other fingers replacement arthroplasty may be required however results are variable and re‐ operation rates are high.
DIP and PIP joints can be affected by primary OA, which other joint can be affected?
THE STT JOINT (scaphoid, trapezium, trapezoid)
-May need fusion of carpal bones or wrist fusion
OA of the radiocarpal joint
OA of the radio‐carpal joint of the wrist usually occurs as a consequence of trauma (eg scaphoid non‐union, carpal dislocation). Wrist arthroplasty or fusion may be considered.
RA deformities
Volar MCPJ subluxation
Ulnar deviation
Swan neck deformity (hyperextension at PIPJ with flesion DIPJ)
Boutonniere deformity (flexion at PIPJ with hyperextension at DIPJ)
Z-shaped thumb
Surgery for tendons in RA
Tenosynovectomy (excision of synovial tendon sheath) may prevent tendon rupture. When extensor tendons to the wrist or fingers rupture direct surgical repair is not possible as repair of the diseased tendon will fail. Tendon transfers or joint fusions may be required to preserve function.
Should cysts transilluminate?
Yes
Is the “bible technique” recommended for bursting ganglion?
Lol no
“bible technique” = thumping with a book
Giant cell tumour of the tendon sheath
These are the second most common soft tissue swellings of the hand (after ganglions). They are usually on the palmar surface especially around the PIP joint of the index and middle fingers and are typically well circumscribed but can be diffuse.
They may or may not cause pain, they can envelop the digital nerve or artery and they can erode into bone.
Histologically they contain multinucleate giant cells and haemosiderin (which gives their brown appearance).
Excision is usually recommended to prevent local spread and to treat symtoms. Recurrence is not uncommon (10‐20%).
What is found histologically in a giant cell tumour of the tendon sheath?
Multinucleate giant cells
Haemosiderin
