Spine Pathologies Flashcards
What are the pathologies of the spine?
Prolapsed inter-vertebral disc (PID)
Degenerative disc disease (DlD)
Spinal stenosis
Tumour /metastases
Infections
Multiple sclerosis (MS)
Spina bifida
Osteopenia/ Osteoporosis
What does the cause and level of the injury / pathology have an impact on?
Pain (localised /neurological Pathway)
Neurological symptoms e.g. numbness, bturning, pins/ needles
Mechanical symptoms, function/ dysfunction
What are the vertebral levels?
Cervical : C1-C7
Thoracic: T1- T12
Lumbar: L1- L5
Sacral: S1-S5
What are the spinal nerve root functions upon rest and digest ?
The vagal nerve is stimulated this is called parasympathetic
What are the spinal nerve root functions upon fight on flight?
The vagal nerve is inhabited this is called Sympathetic
What are some Sympathetic nerve root functions?
Pupil dialates
Bronchi relaxes
Heart accelerates
Stimulates glucose release by liver
What are some Parasympathetic nerve root function?
Pupil constricts
Bronchi constricts
Stimulates gallbladder
Relaxes rectum
What is prolapsed Intervertebral Disc (PID)?
Herniation of the nucleus Pulpous within the annulus fibrosus causing Protrusion of the annulus fibrosus into the neural canal
What is the most common cause of spinal Cord and/ or nerve root compression?
Prolapsed intervertebral Disc (PID)
Where is PlD most common in?
Lumbar region especially between L2-S1 and therefore affects nerve roots only
If cervical or thoracic, spinal cord may also be compressed
What Part of the vertebra is the Annulus fibrous and NucIeus Pulposus?
The nucleus pulposus is the center and the Annulus fibrous is the outer part
What are the characterisation of a disc bulge?
Asymmetric Bulging
Diffuse Bulging
What are the characteristics of a Disc Herniation?
Protrusion- Annulus fibrosus is still wide at the sides of the protrusion
Extrusion - Annulus fibrosus is tight at the sides of the protrusion
How likely is a PID to occur?
May occur acutely (suddenly) at any age during strtenuous exercise or exertion
Can also occur progressively in older people with bone disease or disc degeneration /dehydration leads to rupture during minimal exercise
What does a PID hernia cause?
It may be one-sided causing Pressure/ damage to nerve root, or midline- compressing anterior Spinal artery, the spinal cord and possibly and possibly bilateral nerve roots
What are the different types PID?
Median /paramedian
Foraminal
Extra-foraminal
What are the Sign and Symptoms of PID?
Depends on the size of hernia and length of time pressure is applied
Small herniations cause local pain, due to pressure on nerve endings
Large herniations
What does small and large herniations cause?
Small herniations - cause local pain, due to pressure on nerve endings
Large herniations - Unilateral/ bilateral paralysis
- Acute or chronic Pain in the area supplied by the compressed sensory nerve (Leg or foot)
- Local muscle spasm, due to pressure on motor nerves
- Ischaemia and possibly necrosis of the cord, If the spinal artery is compressed
What is the relationship between Aging and degeneration?
Older patients often present with more Chronic or recurrent symptoms of degenerative spinal disease
What are the different types of degeneration?
Progressive narrowing of the spinal canal may occur alone or in combination with either gradual disc dehydration or acute disc herniations
Congenital and acquired spinal stenoses place the patient at a greater risk for acute neurologic injury
What is Degenerative Disc Disease (DDD)?
Degenerative Disc Disease is one of the most common causes of low back pain
The disc basically degenerates losing water and changing it’s Composition of proteins which causes the disc to be less ‘spongy’ and so it cannot act as a shock absorber
What develops when people reach their 6th decade?
They develop tears in the annulus fibrosis
What signs and symptoms and factors of DDD ?
Common LBP (not all will have it)
Typically associated with aging
During the aging process, intervertebral discs, like other joints in the body, can degenerate and become problematic - 1a natural process, as the body deals with years of strain overuse and maybe even misuse
Can be hereditary
Sedentary lifestyle
Obesity
What is the disease process of DDD?
Process means discs lose flexibility, elasticity, and shock absorbing characteristics
Disc becomes dehydrated and less ‘spongy’
This sees them change from a supple state that allows fluid movement to a stiff and rigid state that restricts movement and causes pain
Because of disc changes, the vertebrae can be affected, example - formation of osteophytes due to increased friction as the spine tries to adjust to the intervertebral disc changes
Discs become thinner as they dehydrate, resulting in Joint space narrowing
Common in lumbar and cervical spine
C. spine incidence: C5-6 most common then C6-7 then C4-5
Very rare in thoracic spine
About 90% of all lumbar disc herniations occur at the L4-5 and L5-S1 levels
Nearly all are inside the spinal canal
How to comment on a DDD image.
T2-weighted MRI Sagittal Lumbar spine
Discs at L3/4 and L4 /5 are dehydrated and narrowed
These discs are also protruding Posteriorly into the spinal canal
Loss of alignment of the L spine posteriorly at L4/5 (L5 is slipped forward)
The discs are pressing into the spinal cord
What is spinal stenosis?
Narrowing of the spinal canal resulting in compression of the spinal cord and nerves usally due to te common occurrence of spinal degeneration that occurs with aging
Can be developmental or familial
Can also be caused by disc herniation, Osteoporosis, bone disease (e.g paget’s) or a tumour
What some causes of spinal stenosis?
Can be caused by disc herniation, Osteoporosis, bone disease (e.g paget’s) or a tumour
May affect the cervical, thoracic or lumbar spine
What are some results of lumbar stenosis?
Low back Pain
Pain or abnormal sensations in the legs, thighs, feet or buttocks, or loss of bladder and bowel Control
What are extradural tumours?
They are the most common spinal tumours and are usually of metastatic origin
What are the most common kind of intramedullary tumour?
Ependynomas
Where does Intradural tumors originate?
They arise from the epandyma, a tissue of the central nervous system
Where is the most common place for an Intradural tumour to form?
They are most common in the Intracranial for peads, while in adults it is spinal
What is the responsible for the 40-60% of all intramedullary spinal tumours?
Ependynomas - with an average age of presentation being 35-40 years
Where does most Meningioma occur in?
In the brain with about 12% located in the spine
What is a meningioma?
Second most common tumour in the intradural- extramedullary location
Meningiomas account for approximately 25% of all spinal tumours
Are most intradural spinal tumors benign or malignant?
They are benign and potentially resectable
The Prognosis after surgical resection is excellent
What are the % associated with each location of a meningioma?
Approximately 80% are located in the thoracic spine, followed by Cervical spine (15%), Iumbor spine (3%), and the foramen magnum (2%)
What is a syrinx?
A fluid- filled cavity that develops in the spinal cord - Syningomyelia
This is a rare condition
What is the Prevelance of a syrinx?
In about 50%, it is present at birth, and then for poorly understood reasons, It enlarges during teen or young adult years
What is likely to happen to children who are born with Syrinx?
They also have other structural abnormalities of the brain, spinal cord, or Junction between the skull and spine
What are the main causes of syrinxes that are developed later in life?
Injuries or tumours
What happens to 30% of tumors that originate in the spinal card?
The eventually produce a syrinx
What are the first thing affected by syrinxes that grow in the spinal card?
First affects nerve fibres that carry information about pain and temperature from the body to the brain Then later it affects fibres that carry signals from the brain to stimulate muscle movement
What happens to the spinal cord when a syrinx grows from within?
The syrinx presses on it from the inside
Where in the spinal cord does a syrinx occur?
It can occur anywhere along the lengt of the spinal Cord, but they often begin in the neck and may extend downward to affect the entire cord
What happens to the syrinx that do not grow inside the spinal cord?
Syrinxes that extend into or begin in the lower part of the brain stem may compress Pathways of the spinal cord and cranial nerves (which lead directly from the brain to other parts of the head and neck)
How does a syrinx appear on a TI and T2 weighted Images?
T1 (with contrast)- Hyperintense
T1- Hypointense
T2 - HyperIntense
What are two types of spinal Infections?
Discitis - disc space infection
Osteomyelitis - bony origin
What is the prevalence and Incidence of spinal infections?
1 case per 100,000 -250,000 population
More common in children and middle aged
More common in males than females
What are spinal infections?
Epidural abscess
Associated fever
How does a spinal infection occur?
Through a direct infection/ blood route
20-30% caused by remote infection
It can occur anywhere in the spine but more common in the lumbar region
Are true primary infections common?
No, they are uncommon
How an osteomyelitis & discitis pathology described? (Sample answer)
Destimation of the 23-4 disk space with the adjacent endplate and for vertebral body
L3 and L4 T2 signal, Indicating oedema and for infarction
Also shown is a retropulsion of debris, which compresses the subdural space and spinal cord
What is multiple sclerosis (MS)?
It is a Neurological autoimmune Condition with a wide range of Symptoms
What is the Aetiology of MS?
It is not fully understood - combination of environmental and genetic factors
What image modality is the most effective in revealing demyelinationg plaques?
MRI as it is the most sensitive diagnostic imaging modality
MRI also shows abnormalities in 95% of Patients with clinically definitive MS
What is the % of patients with MS develop spinal lesions at some point as it progresses?
55-75%
How are MS visualised on an MRI?
On unenhanced T1w images, depending on their age, MS plaques may appear as nodules, ring, or arcs and generally are less than 2 vertebral bodies In length
What contrast agent is added in an MRI imaging to demonstrate prompt enhancement of plaques?
The administration of a gadolinium - based agent which usually indicates active disease
The enhancement may last 2-8 weeks
What type of lesions do not demonstrate contrast enhancement?
Classic Chronic lesions
How is MS visualised on a T2w MRI?
Most plaques appear hyperintense on T2w images1
In a T2w image why can the spinaI cord may or may not be focally enlarged?
Enlargement of the card is usually seen with active disease
Larger active lesions may have extensive oedema with associated cord expansion
Chronic lesions often demonstrate focal cord atrophy
What lesions are usually associated with brain lessions?
Spinal lesions
What is the % of spinal MS lesions that are Isolated?
20%
What is spinal cord narrowing caused by?
Due to atrophic changes that is Present in 10% of patients with spinal cord involvement
What is spinal bifida?
It is an open defect, neural tube defect
It occurs mostly in the lumbar spine
What is a myelomeningocele?
It is a cystic Swelling of the dura and arachnoid
It protrudes through the spinal bifida defect in the vertebral arch
What happens to the thoracic vertebrae of spina bifida?
There is no fusion of the pedicle and the spinous process leaving the foramen exposed
What are the risks factors for spina bifida?
Lack of folic acid
Family history
Medication
Genetic
What are the rates of live births of spina bifida?
It varies - 1-5 per 10,000 live births
