spine + other conditions

Question 1

how can spinal stenosis and peripheral arterial disease be differentiated?

Answer 1

spinal stenosis = calf pain is worse walking DOWNHILL (spine flexion creates more soace for cauda equina)

peripheral arterial disease = calf pain is worse on walking UPHILL

Question 2

acute angular deformity in the spine in the sagittal plane

Answer 2

Gibbus

Question 3

back pain red flags

Answer 3

• sudden onset of new back pain over 60s
• neurological lower lib symptoms with bowel or bladder dysfunction
• constant back pain, worse at night
• back pain in under 20s
• back pain with systemic upset

symptoms of cauda equina

Question 4

bed rest = first line in mechanical back pain

Answer 4

FALSE

bed rest not advised as will lead to stiffness and spasm of the back which may exacerbate disability

Question 5

causes of nerve root compression in cauda equina

Answer 5

• herniated disc - most common
• tumours - metastasis
• spondyliosthesis (anterior displacement of a vertebra out of line with the one beneath
• abscess - infection
• trauma

Question 6

what do the nerves of cauda equina supply

Answer 6

• sensation to perineum, bladder + rectum
• motor innervation to lower limbs + anal + urethral sphincters
• parasympathetic innervation of bladder + rectum

Question 7

cauda equina presentation (red flags)

Answer 7

saddle anaesthesia - “normal when you wipe?”
not knowing when bladder + rectum full (loss of sensation)
urinary/faecak retention + incontinence
bilateral sciatica
bilateral or severe motor weakness in legs
reduced anal tone on PR exam

Question 8

cauda equina investigations

Answer 8

PR exam is mandatory

urgent MRI

Question 9

causes of sciatica

Answer 9

when sciatic nerve is irritated or compressed (lumbosacral nerve root compression)

• herniated disc
• spondylolisthesis
• spinal stenosis

Question 10

sciatica presentation

Answer 10

unilateral electric/shooting pain from buttock radiating down back of thigh to below knee or foot
pins + needles (paraesthesia)
numbness
motor weakness
reflexes may be affected depending on root

Question 11

which nerves make up the sciatic nerve

Answer 11

L4 - s3 spinal nerves

Question 12

management of sciatica

Answer 12

first line = analgesia, maintaining mobility, physio (most spontaneously resolve by 3 months)

neuropathic pain if persisiting - gabapentin, amitriptyline

very occasionally surgery - discectomy

Question 13

acute disc tear

Answer 13

• after lifting heavy object
• pain worse on coughing - increases disc pressure
• analgesia + physio
• can take 2-3months to settle

Question 14

causes of spinal stenosis

Answer 14

bulging discs
ligamentum flavum
osteophyte

Question 15

spinal stenosis presentation

Answer 15

usually over 60
claudication (pain in legs when walking)
- cladication distance is inconsistent
- pain is burning
- pain is less walking up hill
- pedal pulse preserved

Question 16

spinal stenosis management

Answer 16

physio, weight loss

persisting symptoms + MRI evident of stenosis -> surgery (increase space for cauda equina)

Question 17

osteomyelitis

Answer 17

• inflammation in bone + bone marrow
• usually caused by bacterial infection
• acute or chronic
• may recur

Question 18

most common causative organism in osteomyelitis

Answer 18

staph aureus

Question 19

how is infection spread in osteomyelitis

Answer 19

most common = haematogenous = pathogen carried through blood + seeded in the bone

• adults - vertebra
• kids - long bones

direct contamination = at fracture site or during orthopaedic operation

Question 20

risk factors for osteomyelitis

Answer 20

open fractures
operation - esp prosthetic joints (often revision surgery - prophylactic antibiotics given)
diabetes - diabetic foot ulcers
perippheral arterial disease
IV drug use

Question 21

osteomyelitis presentation

Answer 21

fever
pain + tenderness
erythema
swelling
(symptoms can be very non-specific)

Question 22

osteomyelitis investigations

Answer 22

x-ray - often show nothing, periosteal reaction, localised osteopenia

MRI
blood tests - inflam markers
blood + bone cultures

Question 23

management of osteomyelitis

Answer 23

surgical debridement of infected bone + tissues
antibiotic therapy

osteomyelitis associated with prosthetic joint - may require complete revision surgery to replace prosthesis

Question 24

antibiotic treatment in acute + chronic osteomyelitis

Answer 24

acute = 6 weeks of fluclox - possibly with rifampicin or fusidic acid for first 2 weeks

• • clindamycin if pen allergic
• • vancomycin or teicoplanin when MRSA

chronic = 3 months antibiotics

Question 25

is the fascia that surround the fascial compartments stretchy?

Answer 25

NO !

Question 26

compartment syndrome

Answer 26

pressure within fascial compartment is elevated cutting blood flow contents of that compartment

!! emergency - not prompt, damage can occur

Question 27

compartment syndrome presentation

Answer 27

post-acute injury (bone fractures, crush injuries)
5 Ps
- pain - *disproportionate to underlying injury, worsened by passive stretching of muscles
- paraesthesia
- pale
- pressure (high)
- paralysis - late + worrying feature

Question 28

difference between 5 Ps of compartment syndrome + limb ischaemia

Answer 28

pulseless is NOT a feature of compartment syndrome

Question 29

how can compartment pressure be measured?

Answer 29

needle mamometry - injecting saline into compartment

Question 30

management of compartment syndrome

Answer 30

initially = elevate leg to heart level, maintain good bp (avoid hypotension)

emergency fasciotomy to relieve pressure

• debride any necrotic tissue
• wound is left open + covered
• trips to theatre every few days to check for necrotic tisue
• can take several weeks - skin graft may be required if wound cannot be closed around compartment

Question 31

chronic compartment syndrome

Answer 31

associated with exertion - pressure falls during rest, symptoms made worse by activity + resolve quickly in rest

Ix = needle mamometry before during + after exertion

treatment = fasciotomy