Spine pathology + bone tumours Flashcards
L5 radiculopathy
Weakness of hip abduction
Weakness in foot and big toe dorsiflexion - foot drop
Sensory loss of dorsum of foot
+ve sciatic nerve stretch test
Sciatic neuropathy
Loss of ankle jerk and plantar response
Loss of knee flexion and power below knee
L3 root compression
Sensory loss over anterior thigh
Weak quadriceps - Reduced knee extension
Weak hip flexion and hip adduction
Absent knee jerk test
Positive femoral stretch test
L4 nerve root compression
Sensory loss of anterior aspect of knee
Weak quads - Reduced knee extension
Absent knee reflex
Positive femoral stretch test
S1 nerve root compression
Sensory loss of posterolateral aspect of leg and lateral foot and sole of foot
Weak plantar flexion
Reduced ankle reflex
+ve sciatic nerve stretch test
RF for primary bone cancers
RB1 and p53 mutation - osteosarcoma in children
TSC1/2 mutation - chondroma during childhood
Exposure to alkylating agents in chemotherapy and radiotherpay
Pagets disease and fibrous dysplasia
Which bone tumours show soap bubble appearance on Xray
Giant cell tumours
Bone tumour causing Codman’s triangle or sunburst pattern on Xray
Osteosarcoma
Bone tumour causing onion skin pattern on Xray
Ewing’s sarcoma
Bone tumour causing lytic lesions with calcification, endosteal scalloping and cortical remodelling on Xray
Chondrosarcoma
Pott’s disease
Vertebral TB
Back pain and neurological features
Low grade fever
MRI gold standard
L4 sciatica distribution of pain
Anterior thigh
Anterior knee
Medial leg
L5 sciatica distribution of pain
Lateral thigh
Lateral leg
Dorsum of foot
S1 sciatica
Posterior thigh
Posterior leg
Heel
Sole of foot
Sciatic nerve roots
L4 - S3
Femoral nerve roots
L2 - L4
Obturator nerve roots
L2 - L4 anterior divisions
Common bone metastasis
Prostate Breast Kidney Thyroid Lung
Symptoms of bone tumours
Pain not associated with movement
Worse at night
Pathological fractures - without trauma
Osteoid osteoma summary, age, presentation, Mx
Benign Arise from osteoblasts 10 - 20 yrs old Males > females Metaphysis of long bones
Symptoms:
- progressive localised pain
- worse at night
- Better with NSAIDs
- can have localised swelling, tenderness and limping
Mx:
- serial X-ray - every 4 - 6 months
- surgical resection - if severe pain
Osteochondroma summary, age, presentation, Mx
Benign
Outgrowth from metaphysis covered with a cartilaginous cap
10 - 20 yrs old
Normally asymptomatic and slow growing
Can cause deformity of impinge on nerves if large
Ix:
- X-ray - pedunculated growth on metaphysis
Mx:
- conservative management with serial X-ray - 4 - 6 months
- if symptomatic and large - surgical resection
Chondroma summary, age, presentation, Mx
Benign
Arise from chondroblasts - within medulla
20-50 years old
Affecting the long bones of the hands, femur, and humerus
Symptomatic
Pathological fractures
Ix:
Xray - well circumscribed oval lucency with intact cortex
Mx:
- conservative - observation if asymptomatic and small
- large or symptomatic chondromas may require removal with curettage and bone grafting
Giant Cell Tumour summary, age, presentation, Mx
Benign
Arise from the multinucleated giant cells and stromal cells - affects epiphysis of long bones
20-30 years old
Symptoms:
- pain
- swelling
- limitation of joint movement
Ix:
Xray - eccentric lytic area, giving a “soap bubble” appearance
Mx:
Surgical resection - may require bone grafting or reconstruction
Most common malignant primary bone tumour
Osteosarcoma
Osteosarcoma
Malignant
Found in metaphysis of the distal femur or proximal tibia
Either at 10-14 years or in those >65yrs
RF: Paget’s disease
Symptoms:
- localised constant pain and a tender soft tissue mass may be palpable
Ix:
- Xray - medullary and cortical bone destruction + periosteal reactions- Codman’s triangle” or as a “sunburst pattern”
- Tissue biopsy
Mx:
- aggressive surgical resection with systemic chemotherapy
Where does osteosarcoma metastasis to
Lung and bone
Ewing’s Sarcoma
Paediatric malignancy
M>F
Arise from primitive poorly differentiated neuroectodermal cells - commonly affect the diaphysis of long bones
Symptoms:
- painful and enlarging mass - tenderness and warmth
Ix:
Xray - lytic lesion with periosteal reactions -producing layers of reactive bone - “onion skin” appearance
Mx:
- neoadjuvant chemotherapy followed by surgical excision
- radiotherapy if unresectable
Chondrosarcoma
Malignant tumours of the cartilage
Onset is 40-60 yo
Affects axial skeleton - especially pelvis, shoulder, and ribs
Symptoms:
- painful and enlarging mass
Ix:
Xray - lytic lesions with calcification, cortical remodelling, and endosteal scalloping
Mx:
Low grade lesions- intralesional curettage
Intermediate- and high-grade lesions -wide en-bloc local excision
Radiological Features of Bone Tumours
Benign - sharp and well-defined, lacking soft tissue involvement and no cortical destruction
Malignant - poorly defined with rough borders, involving soft tissues and have cortical destruction
Radiculopathy
Conduction block in the axons of a spinal nerve or its roots
- motor axons - weakness
- sensory axons - paraesthesia
Radicular pain
pain from damage or irritation of the spinal nerve tissue, particularly the dorsal root ganglion
Causes of radiculopathy
Compression due to:
- Intervertebral disc prolapse
- Degenerative diseases of the spine
- Fracture
- Malignancy
- Infection - Extradural abscess, osteomyelitis, Pott’s disease (TB) or herpes zoster
Mx of radiculopathy
Amitriptyline
Pregabalin and gabapentin as alternatives.
Muscle spasms -benzodiazepines (often diazepam) or baclofen
Physio
Lasègue Test
Straight leg raise - assess for disc herniation
With the patient lying down on their back, the examiner lifts the patient’s leg while the knee is straight. The ankle can be dorsiflexed and / or the cervical spine flexed for further assessment.
Degenerative disc disease mx
Pain relief - NDAIDs or co - codamol
Activity - encouraging motility
Physiotherapy - strengthening the core
Jefferson Fracture
Atlas C1 burst fracture
Due to axial loading of cervical spine
Hangman’s Fracture
Fracture through the pars interarticularis of C2 (axis) bilaterally
Due to cervical hyperextension and distraction
Odontoid Peg Fractures
Most common in older patients
Low-impact injuries and neck pain
Can be fatal, especially with significant displacement of the odontoid; those who survive can have no neurology
Investigations for cervical fractures
CT scan
MRI scan - for children
Management of cervical spine fractures
ATLS
3 point C spine immobilisation
Analgesia and admit
Stable:
- rigid color and halo vests
Unstable:
- Posterior fixation - pedicle scres and rods
- Fusion - across the injured segment of the spine to the uninjured segments above and below, with or without decompression of the vertebral canal.
