spine + other conditions Flashcards
how can spinal stenosis and peripheral arterial disease be differentiated?
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
acute angular deformity in the spine in the sagittal plane
Gibbus
back pain red flags
- 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
bed rest = first line in mechanical back pain
FALSE
bed rest not advised as will lead to stiffness and spasm of the back which may exacerbate disability
causes of nerve root compression in cauda equina
- herniated disc - most common
- tumours - metastasis
- spondyliosthesis (anterior displacement of a vertebra out of line with the one beneath
- abscess - infection
- trauma
what do the nerves of cauda equina supply
- sensation to perineum, bladder + rectum
- motor innervation to lower limbs + anal + urethral sphincters
- parasympathetic innervation of bladder + rectum
cauda equina presentation (red flags)
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
cauda equina investigations
PR exam is mandatory
urgent MRI
causes of sciatica
when sciatic nerve is irritated or compressed (lumbosacral nerve root compression)
- herniated disc
- spondylolisthesis
- spinal stenosis
sciatica presentation
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
which nerves make up the sciatic nerve
L4 - s3 spinal nerves
management of sciatica
first line = analgesia, maintaining mobility, physio (most spontaneously resolve by 3 months)
neuropathic pain if persisiting - gabapentin, amitriptyline
very occasionally surgery - discectomy
acute disc tear
- after lifting heavy object
- pain worse on coughing - increases disc pressure
- analgesia + physio
- can take 2-3months to settle
causes of spinal stenosis
bulging discs
ligamentum flavum
osteophyte
spinal stenosis presentation
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
spinal stenosis management
physio, weight loss
persisting symptoms + MRI evident of stenosis -> surgery (increase space for cauda equina)
osteomyelitis
- inflammation in bone + bone marrow
- usually caused by bacterial infection
- acute or chronic
- may recur
most common causative organism in osteomyelitis
staph aureus
how is infection spread in osteomyelitis
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
risk factors for osteomyelitis
open fractures operation - esp prosthetic joints (often revision surgery - prophylactic antibiotics given) diabetes - diabetic foot ulcers perippheral arterial disease IV drug use
osteomyelitis presentation
fever pain + tenderness erythema swelling (symptoms can be very non-specific)
osteomyelitis investigations
x-ray - often show nothing, periosteal reaction, localised osteopenia
MRI
blood tests - inflam markers
blood + bone cultures
management of osteomyelitis
surgical debridement of infected bone + tissues
antibiotic therapy
osteomyelitis associated with prosthetic joint - may require complete revision surgery to replace prosthesis
antibiotic treatment in acute + chronic osteomyelitis
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
is the fascia that surround the fascial compartments stretchy?
NO !
compartment syndrome
pressure within fascial compartment is elevated cutting blood flow contents of that compartment
!! emergency - not prompt, damage can occur
compartment syndrome presentation
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
difference between 5 Ps of compartment syndrome + limb ischaemia
pulseless is NOT a feature of compartment syndrome
how can compartment pressure be measured?
needle mamometry - injecting saline into compartment
management of compartment syndrome
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
chronic compartment syndrome
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
