Spine orthopaedics and trauma Flashcards
Which myotome facilitates hip flexion?
L1/2
Which myotome facilitates knee flexion?
L3/4
Which movements does the L5 myotome facilitate?
Foot dorsiflexion and extensor hallicus longus
Which myotome facilitates plantarflexion?
S1/2
What is sciatica?
Buttock and/or leg pain in a specific dermotomal distribution accompanied by neurological disturbance
What is shown on this MRI?
Slipped disc
What is a slipped.herniated disc?
A tear in the annulus fibrosis of an intervertebral disc allows the nucleus pulposis to bulge out beyond the damaged outer rings
What are some of the causes of disc herniation?
Age-related degeneration
Trauma
Lifting injuries
Straining
What direction is spinal disc herniation usually in and why?
Postero-laterally
The presence of the posterior longitudinal ligament prevents the disc from herniating directly posteriorly
What is the presentation of an acute disc tear?
Typically occurs after lifting heavy object
Acute onset back pain
Worse on coughing
How does sciatica present?
Lower back pain
Buttock pain and numbness
Pain or weakness in various parts of the leg and foot
“pins and needles”
Tingling and difficulty moving or controlling the leg
What causes sciatica?
Compression or irritation of one of the five nerve roots of the sciatic nerve e.g. by a herniated disc causing compression
How is disc prolapse managed?
Conservatively intially
Consider surgery if not resolving after 3 months
Surgery is to treat leg pain
How is backache managed conservatively?
Anti-inflammatory and/or muscle relaxant
Physiotherapy
Xray
Return to normal activity
What are the red flag symptoms with back pain?
First back pain age <20 or >50
Non-mechanical, constant pain
History of cancer
History of steroids
Systemic upset/weight loss
Structural deformity
Saddle anaesthesia/paraesthesia and loss of bowel and bladder control
Severe pain longer than 6 weeks
What is cauda equina syndrome?
A serious neurologic condition in which damage to the cauda equina causes acute loss of function of the lumbar plexus
How does mechanical back pain present?
Recurrent relapsing and remitting back pain with no neurological symptoms
Worse on movement, relieved by rest
Aged between 20-60 and have had previous ‘flare ups’
What are some of the causes of mechanical back pain?
Obesity
Poor posture
Poor lifting technique
Lack of physical activity
Depression
Degenerative disc prolapse
Facet joint OA
Spondylosis
What is spondylolysis?
The intervertebral discs lose water content with age resulting in less cushioning and increased pressure on the facet joints leading to secondary OA
Why is bed rest not advised in mechanical back pain?
This will lead to stiffness and spasm of the back which may exacerbate disability
What are the symptoms of an L3/L4 prolapse and what nerve is compressed?
L4 root entrapped
Pain down to medial ankle (L4), loss of quadriceps power, reduced knee jerk
What are the symptoms of an L4/L5 disc prolapse and which nerve is compressed?
L5 nerve root entrapment
Pain down dorsum of foot
Reduced power Extensor Hallucis Longus and tibialis anterior
What are the symptoms of an L5/S1 prolapse and which nerve is compressed?
S1 nerve root entrapment
Pain to sole of foot, reduced power planarflexion, reduced ankle jerks
What is spinal stenosis?
When the cauda equina of the lumbar spine has less space due to a combination of bulging discs, bulging ligamentum flavum and osteophytosis
What is the primary symptom of spinal stenosis?
Claudication
How does spinal claudication differ from vascular claudication?
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
What are the symptoms of cauda equina syndrome?
Bilateral leg pain
Paraesthesiae or numbness and complain of “saddle anaesthesia”
Urinary retention/incontience
Constipation/bowel incontinence
What is the management of cauda equina syndrome?
Urgent MRI
Urgent discectomy
How are osteoporotic fractures of the lumbar spine managed?
Usually conservatively
What cervical spine pathology are children with Down’s syndrome at risk of developing?
Atlanto‐axial (C1/C2) instability with subluxation potentially causing spinal cord compression
How is atlanto-axial instability screened for in Down’s syndrome?
Screening with flexion‐extension xrays will demonstrate the abnormal motion
How does atlanto-axial instability occur in RA patients?
Destruction of the synovial joint between the atlas and the dens and rupture of the transverse ligament
What criteria must be met in order to clinically clear a C-spine?
No history of loss of consciousness
GCS 15 with no alcohol intoxication
No significant distracting injury (such as head injury, chest trauma or other fractures including more distal spinal fractures)
No neurological symptoms in the upper or lower limbs
No midline tenderness on palpation of the c-spine
No pain on gentle active neck movement (ask the patient to gently flexed forward, then rotate to each side)
Which C-spine fractures may be fatal?
High - especially C3 and above (phrenic nerve)
Do osteoporotic thoracolumbar wedge fractures require any surgery?
No
What proportion of thoracolumbar wedge fractures have associated neurological problems?
15-20%
What are the indications for surgical repair of thoracolumbar spinal fractures?
Presence of neurological deficit especially if progressive or very unstable injury
Unstable injury pattern with substantial loss of vertebral height, displacement or involvement of the posterior ligamentous structures
How can stable injuries of the thoracic spine be treated and what are they protecting?
A brace to limit flexion and prevent kyphosis
How might more stable lumbar lordosis fractures be treated?
A plaster jacket to preserve the lumbar lordosis
What is ‘spinal shock’?
A physiologic response to injury with complete loss of sensation and motor function and loss of reflexes below the level of the injury
How long does it usually take for spinal shock to resolve?
Roughly 24 hours
What is the bulbocavernous reflex?
A reflex contraction of the anal sphincter with either a squeeze of the glans penis, tapping the mons pubis or pulling on a urethral catheter
How is the bulbocavernous reflex used clinically?
It is absent in spinal shock
Its return signals the end of spinal shock
When does neurogenic shock occur?
Secondary to temporary shutdown of sympathetic outflow from the cord from T1 to L2
Usually due to injury to the cervical or upper thoracic cord
What are the symptoms of neurogenic shock?
Hypotension and bradycardia which usually resolves within 24‐48 hours
Priaprism may be present due to unopposed parasympathetic flow
How is neurogenic shock treated?
IV fluid therapy
How can spinal cord injuries be classified?
Complete or incomplete
What is complete spinal cord injury?
Complete spinal cord injury results in no sensory or voluntary motor function below the level of the injury (reflexes should return)
How is the level of the injury (spinal cord) determined?
The most distal spinal level with partial function (after spinal shock has resolved) as determined by the presence of dermatomal sensation and myotomal skeletal muscle voluntary contraction
What is the prognosis for recovery from complete spinal cord injury?
Poor
What are incomplete spinal cord injuries?
Injuries with some neurologic function (sensory and/or motor) is present distal to the level of injury
What signs are indicators of continuity of motor and sensory tracts in the distal spinal cord?
Sacral sparing with preservation of perianal sensation, voluntary anal sphincter contraction and big toe flexion (FHL muscle, S1/2)
When might ventilatory support be required in spinal cord injury?
Loss of intercostal muscle function (T1-12)
What is central cord syndrome?
A form of cervical spinal cord injury characterised by loss of motor and power and sensation in the arms and hands
Why are the arms more paralysed than the legs in central cord syndrome?
The upper limb supply tends to be more to the center of the spinal cord
How does central cord syndrome typically occur?
A hyperextension injury in a cervical spine with osteoarthritits
What is Brown-Sequard syndrome?
An incomplete spinal cord injury characterised by ipsilateral paralysis and loss of dorsal column sensation occurs with contralateral loss of pain, temperature and coarse touch sensation
