Spine Pathology Flashcards
What is cauda equina syndrome?
Compression of cauda equina/sacral nerve roots
What causes cauda equina syndrome?
Central lumbar disc prolapse
Malignancy
Trauma: Fractured disc
Spinal stenosis
Infection: Epidural abscess
Iatrogenic: Spinal surgery, Spinal epidural injection
How does cauda equina present?
Injury or precipitating event
Bilateral leg and buttock pain and weakness
‘Numb bum’/Saddle Anaesthesia: Perianal loss of sensation, loss of anal tone and anal reflex
Bowel or bladder dysfunction: Urinary retention, Incontinence overflow
What investigation is used in cauda equina diagnosis?
Urgent MRI of lumbar-sacral spine within 6 hours
- If contraindicated then lumbar CT myelogram
How is cauda equina managed?
Emergency operation within 24 hours of onset: Realistically ASAP as delay results in permanent dysfunction
Give complications of cauda equina syndrome
Sacral nerve roots compressed can result in permanent bladder and anal sphincter dysfunction and incontinence
How does spinal claudication present?
Usually bilateral
Sensory dysesthesia
Postural weakness: Foot drop which causes tripping
Takes several minutes to ease after stopping walking
Worse walking down hills as the spinal canal becomes smaller in extension
Better walking uphill or riding bicycle: Vascular is worse going up due to metabolic demand
What causes spinal stenosis?
Malignancy
Disc prolapse
Degenerative changes
How does spinal stenosis present?
Back pain
- Relieved by sitting down or leaning forward
- Worsens with activity
- Patients find it easier to walk uphill than downhill
What investigations are used in spinal stenosis diagnosis?
MRI, demonstrates canal narrowing
What are the two parts of a intervertebral disc?
Annulus fibrosus is tough outer layer and nucleus pulposus is gelatinous core
What root is the most common cervical disc prolapse?
C5/6
What root is the most common thoracic disc prolapse?
75% T8-12, most at T11/12
What roots are the most common lumbar disc prolapse?
Usually L4/5 (45%), followed by L5/S1 (40%) then L3/4 (10%)
How do disc prolapses present?
Leg pain usually worse than back/dermatomal leg pain
Pain often worse when sitting
How are prolapsed discs managed?
Similar to that of other musculoskeletal lower back pain
- Analgesia/Gabapentin
- Physiotherapy
if symptoms persist after 4-6 weeks, then referral for consideration of MRI is appropriate
What is spondylolisthesis?
Anterior vertebral translation/slippage, often caused by spondylosis
What classification system is used to classify Spondylolisthesis radiographically?
Meyerding
What classification system is used to classify spondylolisthesis aeitiologically?
Wiltse
Give feaures of spondylolisthesis?
Acute back pain
Weakness
Prominent sacrum
Young athletes
How is spondylolisthesis managed?
Conservative/Lifestyle changes
Surgery for persistent pain and nerve root entrapment
What is spondylosis?
Defect of pars interarticularis usually affecting L4/L5
How does spondylosis present?
Lower back pain
What causes spinal cord injury?
Road traffic accidents
Sport and recreational activities
Falls
Degenerative orthopaedic causes
Tumours
Spinal cord stroke/infarction
Transverse myelitis/infection
Thoracoabdominal aortic aneurysm (TAAA)
Describe complete spinal cord injury
No function below trauma
No motor or sensory function distal to lesion
No anal squeeze
No sacral sensation (test sacral nerve roots)
ASIA grade A
No chance of recovery
Describe incomplete spinal cord injury
Variable function
Some function is present below site of injury (sensation in genitals, some lower limb movement etc)
More favourable prognosis overall, trying to prevent further injury
Why can’t we determine if spinal cord injury is complete or incomplete acutely?
Patient may be in spinal shock
What is the classification system for spinal cord injury?
ASIA
What are the types of spinal cord injury?
Tetraplegia/Quadriplegia
Paraplegia
Central cord syndrome
Anterior cord syndrome
Brown-Sequard syndrome
What is tetraplegia/quadriplegia?
Partial or total loss of use of all four limbs and the trunk
What causes tetraplegia/quadriplegia?
Cervical fracture
How does tetraplegia/quadriplegia present?
Respiratory failure due to loss of innervation of the diaphragm (C3-C5)
Spasticity/Increased muscle tone
Loss of motor/sensory function in cervical segments
What is paraplegia?
Partial or total loss of the use of the lower-limbs
What causes paraplegia?
Thoracic/lumbar fractures with associated chest or abdominal injuries
How does paraplegia present?
Arm function spared
Possible impairment of function in trunk
Bladder/bowel function affected
Spasticity if injury of spinal cord (above L1)
Impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord
What causes central cord syndrome?
Older patients
Hyperextension injury, due to trip or fall
How does central cord syndrome present?
Centrally cervical tracts more involved
Weakness of arms > legs
Perianal sensation and lower extremity power preserved
What causes anterior cord syndrome?
Hyperflexion injury
Anterior compression fracture
Damaged anterior spinal artery (usually due to infarction)
How does anterior cord syndrome present?
Fine touch and proprioception preserved
Profound weakness
What is Brown-Sequard Syndrome?
Hemi-section of the cord
What causes Brown-Sequard syndrome?
Penetrating injuries
How does Brown-Sequard syndrome present?
Paralysis on affected site (corticospinal)
Loss of proprioception ad fine discrimination (dorsal columns)
Pain and temperature loss on the opposite side below the lesion (spinothalamic)
Describe ASIA grade A
Complete
No sensory or motor function preserved in sacral segments S4-S5
Describe ASIA grade B
Incomplete
Sensory but not motor function preserved below the neurologic level and extending through sacral segments S4-S5
Describe ASIA grade C
Incomplete
Motor functio presevered below the neuroloic level
Majority of key muscles have a grade <3
Describe ASIA grade D
Incomplete
Motor function preserved below the neurologic level
Majority of key muscls have a grade >3
Describe ASIA grade E
Normal motor and sensory function
What is an iliopsoas abscess?
Collection of pus in iliopsoas compartment
What organism is most commonly associated with iliopsoas abscess?
Staph aureus
Give secondary causes of iliopsoas abscesses
Crohn’s
Diverticulitis
Colorectal cancer
UTI
Femoral catheter
Endocarditis
IVDU
Give features of iliopsoas abscess
Fever
Back/flank pain
Lying flat on his back with his knees flexed
Limp
Weight loss
Hyperextension of affected hip should elicit pain as stretches the iliopsoas muscle
What investigations are used in iliopsoas abscess diagnosis?
CT abdomen
How are iliopsoas abscesses managed?
Antibiotics
Percutaneous drainage, successful in 90%
Surgery if failure
How does discitis present?
Back pain
Pyrexia
Rigors
Neurological features if epidural abscess develops
What organism is the most common cause of discitis?
Staph aureus
How is discitis managed?
6-8 weeks IV antibiotics
Assess patient for endocarditis
What is first line management for lower back pain?
Oral NSAIDS
