Spine Disorders Flashcards
Name the five parts of the vertebrae which protects the spinal cord.
Cervical
Thoracic
Lumbar
Sacrum
Coccyx
RECAP- which regions of the vertebrae have lordosis curvatures?
Lumbar
Cervical
RECAP- which regions of the vertebrae have kyphosis curvatures?
Thoracic
Sacral
What is the purpose of the curvatures of the spine?
Allows for distribution of weight
There are three regions of the cervical spine- which region is found at C1-2?
Atlanto-axial joint
There are three regions of the cervical spine- which region is found at C3-6?`
Subaxial spine
There are three regions of the cervical spine- which region is found at C7?
Transitional vertebrae
Briefly describe the atlas.
No body
No spinous processes
Large transverse processes
Transverse processes are penetrated by the foramen transversarium on each side in which the vertebral arteries pass through.
What name is given to the sticky out point of the axis?
Odontoid process/ dens or peg
What does C7 mark?
Cervicothoracic junction
What are the uncinate processes of the cervical spine?
Bony prominences which restrict lateral flexion
Where would you find the uncovertebral joints?
Between the uncinate processes and superior vertebrae
What do the uncovertebral joints serve as a surgical landmark for?
Placed closely to vulnerable vertebral artery
What happens to the width and height of the pedicles of the thoracic spine as you go down?
Height and width of thoracic pedicles increases
Which bones articulate with the thoracic vertebrae?
Ribs at costovertebral joint
Which section of the vertebrae has the biggest body?
Lumbar
What crosses the lateral zone of the sacrum laterally?
Sympathetic trunk
Lumbosacral trunk
Obturator nerve
Where would you find the anterior and posterior atlanto-occipital membranes?
Between C1 and corresponding parts of foramen magnum
The anterior atlanto-occipital membrane continues down as which ligament?
Anterior longitudal ligament
Which ligament is a very strong ligament and is important to look at when screening a patient with a spinal problem to ensure the ligament is in tact?
Transverse ligament
->the first lecture just goes into loads of detail about the anatomy of the spine, including ligaments and joints. I have stopped making flashcards on them as not sure if it’s a good use of our time but could be worth watching the lecture again to refresh the year one anatomy
What does spinal stability depend on in regards to the three-column theory?
At least two intact columns
->if there is a fracture in one part e.g. the anterior part, but the middle and posterior part are fine, spinal stability will be present
How many spinal nerves in each section of the spinal cord?
Cervical -8
Thoracic- 12
Lumbar- 5
Sacral- 5
Coccygeal- 1
->eight in cervical as first one arises superior to C1
Therefore, where would the C5 spinal nerve be?
Between C4 and 5
Which spinal nerve arises between C7 and T1?
C8 spinal nerve
Therefore, which spinal nerve is found between T4 and 5?
T4
->this is due to the extra cervical spinal nerve so in the cervical region, always nerve and one above, in the rest, the nerve and the one below
Which reflex is lost in spinal shock?
Bulbocavenosus reflex
What is measured to assess neural tube defects in the foetus?
Alpha-fetoprotein (AFP)
What causes spina bifida?
Failure of closing of the posterior neuropore
What is spina bifida?
Birth defect in which there is incomplete closure of the spine and membranes around the spinal cord
What are some risks factors for spina bifida?
Lows folic acid levels beforeic acid deficiency
Family history
Diabetes
Obesity
Anti-seizure drugs
What are the two classifications of spina bifida?
Spina bifida aperta- open spina bifida
Spina bidifa occulta- closed spina bifida
Spina bifida can occur anywhere along the spine but where is the most common site?
Lumbosacral region
In which type of spina bifida is there something seen on the skin of the child, like a sac filled with CSF?
Spina bifida aperta (open)
What is the clinical presentation of spina bifida?
Back swelling
Lower limb motor defect
Sensory deficit
Sphincteric disturbance
Associated back deformities
Name two types of spina bifida aperta.
Meningocele
Myelomeningocele
In which type of spina bifida aperta is there neurological deficit?
Myelomeningocele
In which type of spina bifida aperta is there more commonly a skin covered sac?
Meningocele
->in myelominingocele, the sac covering is usually membranous
In which type of spina bifida aperta is there more commonly an association with hydrocephalous?
Myelomeningocele
What is the treatment of myelomeningele?
Primary surgical closure within 24hrs
If the baby with myelomeningocele has other abnormalities which means they cannot have general anaesthetic, what can be done to delay closure?
Broad-spectrum antibiotics
If the baby has congenital hydrocephalous, what should b treated first?
Hydrocephalous
->sometimes both treated in same surgery
How is hydrocephalous treated?
By putting in a VP (ventriculoperitoneal) shunt
Why should hydrocephalous be treated first?
If not, the high CSF pressure may open the sutures used to close the spine.
CSF can leak out and meningitis may occur
If a baby is born with myelomengocele and leg weakness, what will surgery do?
Will not improve leg weakness but prevents complications
What is tethered cord syndrome?
Inelastic anchoring of the caudal spinal cord but abnormally thick or fatty filum terminale
What happens to the spinal cord in tethered cord syndrome?
It is abnormally stretched and elongated
List some types of spinal infection.
-Pyogenic Vertebral Osteomyelitis and Discitis
-Granulomatous infections
-Epidural infections
-Postoperative infections
What does discitis usually arise from?
Hamatogenous spread
Which region of the spine is most commonly involved in pyogenic infection?
Lumbar
Which microorganisms are the most common causes of pyogenic vertebral osteomyelitis and discitis?
Straph Aureus
Sreptococci
How do patients with pyogenic vertebra; osteomyelitis and discitis present clinically?
Axial back pain
Fever
Neurological changes in 1/3 of patients
What two things should always be asked about in history in patients with infection?
Travel history
Recent procedures
What would labs show in patients with pyogenic vertebral osteomyelitis and discitis?
Possible WBC increase
CRP elevated
->urinalysis and culture should also be investigated
Which neuroimaging may be used in pyogenic vertebral osteomyelitis and discitis?
Plain x-ray
CT
MRI
What is the first-line treatment for vertebral osteomyelitis and discitis?
Broad-spectrum IV antibiotics for at least 6-8 weeks until culture-specific regimens may be initiated.
Identify pathogen before initiating treatment e.g. biopsy, bloods etc.
When may surgery be appropriate in those with ow do we treat vertebral osteomyelitis and discitis?
If:
-appropriate medical management fails
-there is decompression of neural structures
-there is spinal instability or deformity
When do postoperative surgical site infections usually arise?
Following direct inoculation of the wound with normal skin flora
What are some risk factors for postoperative infections?
Increased age
Obesity
Diabetes
Smoking
Poor nutrition
Prolonged surgery time
How are postoperative infections prevented?
Prophylactic antibiotics administered an hour before a spinal procedure.
Additional doses of intraoperative antibiotics should be dispensed for prolonged surgical procedures with significant blood loss or gross contamination.
What is the treatment for postoperative infections?
IV antibiotics for minimum of six weeks
(can switch to oral depending on course and labs)
Spinal cord tumours can be classified as intradural or extradural. What does this mean?
Intradural- within dural sac
Extradural- outwith dural sac
What would a tumour be classified as if it was within the dural sac but outside neural tissue?
Intradural extramedullary tumour
(if inside neural tissue- intramedullary)
What does the clinical presentation of spinal cord tumours depend on?
Location and extent of cord or nerve root compression
Which type of imaging is used to identify spinal cord tumours?
Plain x-ray and CT can be used
MRI is gold standard
What is the treatment for spinal cord tumours?
Surgical excision
Biopsy
Radio and chemotherapy
Give some examples of spinal emergencies.
-Spinal epidural compression- hematomas or abscesses
-Cauda Equina and Conus Syndromes
Spinal hematomas can have many different sites. List them.
Subdural, epidural, subarachnoid, intramedullary
Spinal hematomas are usually localised dorsally to the spinal cord. Where can subarachnoid hematomas be found?
Can extend along the entire subarachnoid space
What can cause spinal hematomas?
Trauma
Anticoagulant therapy
Vascular malformations
No cause identified in 1/3 cases
Symptoms of spinal hematomas depend on location and extent of haemorrhage.
Give some examples of symptoms which may be seen.
Motor weakness
Sensory and reflex deficit
Bowel/bladder dysfunction
What can epidural and subdural hematomas present with?
Intense, knife like pain at location of haemorrhage
What can subarachnoid hematomas present with?
Meningitis like symptoms
Which imaging is gold standard for spinal hematomas?
MRI
What is the treatment for spinal hematomas?
Correction of coagulopathy if present
Emergent surgical decompression if neurological deficit.
What is Cauda Equina Syndrome?
Surgical emergency resulting from compressive, ischaemic and/or inflammatory neuropathy of multiple lumbar and sacral nerve roots.
What can cause cauda equina syndrome?
Trauma
Haemorrhage
Inflammatory diseases
Infection
Degenerative spine diseases
Spine tumours
Where is the cauda equina?
Below L1/2
How can cauda equina syndrome present?
Leg pain, weakness, anaesthesia
Saddle anaesthesia
Bladder, bowel and sexual dysfunction
Decreased anal tone
Absent ankle reflex
Cauda equina syndrome can be complete or incomplete based on the bladder symptoms. What are the symptoms in complete cauda equina syndrome?
Urinary and/or bowel retention or incontinence
Cauda equina syndrome can be complete or incomplete based on the bladder symptoms. What are the symptoms in incomplete cauda equina syndrome?
Loss of urgency
Decreased urinary sensation without incontinence or retention
What is the gold standard of imaging for cauda equina syndrome?
MRI
What is the treatment for cauda equina syndrome?
Surgical decompression within 24hrs
Which region of the spine is most commonly affected by spinal cord injury?
Cervical
(more common higher up, further down, less common)
What is primary spinal cord injury?
Trauma results in the immediate death of local cells, either by direct damage to cell bodies/neuronal processes or by damage to spinous axons.
What happens in spinal cord injury?
Overlapping of inflammation, vascular events, chronic phase of injury involving demyelination or scar formation
What is spinal shock?
Transient loss of all neurological function below the level of the spinal cord injury
What does the loss of all neurological function below level of SCI cause to happen?
Flaccid paralysis and arefelxia (loss of bulbocavernosus reflex)
Shock refers to hypotension, what is the SBP is spinal shock?
Systolic BP <80
What are the multiple factors of the causes of spinal shock?
- Interruption of sympathetics which implies SPI above T1
- Loss of vascular tone
- Relative hypovolemia
- True hypovolemia
What shows that there has been resolution of the spinal shock?
Return of bulbocavernosus reflex.
What happens in the bulbocavernous reflex?
Squeeze glans penis in men and clitoris in women and see if there is contraction of external anal sphincter
After the spinal shock has ended, what would be the symptoms of complete spinal cord injury?
Complete loss of motor and/or sensory function below level of injury
After the spinal shock has ended, what would be the symptoms of incomplete spinal cord injury?
Some residual motor or sensory function below level of injury
Give some examples of types of incomplete spinal cord injury.
Central cord syndrome
Brown-Sequard syndrome
Anterior cord syndrome
Posterior cord syndrome
Which type of incomplete spinal cord injury is the most common?
Central cord syndrome
How does central cord syndrome usually occur?
Due to hyperextension in older patients with pre-existing stenosis
What is the clinical presentation for central cord syndrome?
Motor weakness in upper limb more than lower limb
Sensory loss below level of injury
Urine retention
In central cord syndrome, which limbs recover earlier?
Lower limbs
What may cause anterior cord syndrome?
Occlusion of anterior spinal artery
Anterior cord compression
How does anterior cord syndrome present?
Paraplegia (quadplegia if higher than C7)
Dissociated sensory loss below lesion, loss of pain and temperature but joint position sense and vibration not affected
What does Brown-Sequard Syndrome manifest with?
Ipsilateral loss of joint position sense and vibration.
Contralateral loss of pain and temperature
Ipsilateral spastic paresis below level of lesion
What does the primary assessment and management of spinal cord management involve?
Airway
Breathing
Circulation
Immobilization
What does the secondary assessment of spinal cord injury involve?
Assessment of conscious level using Glasgow Coma Scale
Identifying any axial, appendicular or pelvic skeleton fractures
Which type of X-ray allows good imaging of C1/2?
Open mouth (odontoid view) x-ray
What are some indications for early decompression in spinal cord injuries?
Incomplete spinal cord injury
Patients with progressive neurological deterioration
List possible cervical spine fractures.
Occipital condyle fracture
Atlanto-occipital dislocation
Atlas fracture
Axis fracture
Subaxial cervical spine fractures
What is the most common cause of occipital condyle fractures?
Direct blow to head
What may patients with occipital condyle fractures present with?
Loss of consciousness
Cranio-cervical pain
In which age group is atlanto-occipital dislocation common?
Children due to smaller size of occipital condyles and soft tissue laxity
Atlanto-occipital dislocation is typically an instantly fatal injury. What issues do survivors have?
80% of survivors have neurological deficits
20% have normal findings
Subaxial cervical spine fractures can be divided into which two types?
Ligamentous
Osseous
Name the types of thorco-lumbar spine injuries.
Compression
Burst
Seat belt
Fractures/dislocations
There are three zones of the sacral spine. If there is damage to zone 1 of the sacral spine, which type of injuries will this produce?
Neurological injuries
Usually L5 nerve root or sciatic nerve is damaged
What are the general indications for surgical treatment in spine fractures?
- Occipital condyle avulsion fractures
- Atlanto-occipital avulsion fractures
- More than 5mm C1-2 displacement
- Neurological deficits
- Biomechanical instability
- Non-union after 12 weeks immobilisation
