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Systems: MSK AB > Spine Symposium > Flashcards

Spine Symposium Flashcards

1
Q

What are the 3 main types of vertebrae?

A
  • Cervical
  • Thoracic
  • Lumbar
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2
Q

Other than vertebrae, what other boy structures do the thoracic vertebrae articulate with?

A

Ribs

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3
Q

What natural curvatures of the spine exist?

A
  • Cervical lordosis
  • Thoracic kyphosis
  • Lumbar lordosis
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4
Q

Name the erector spinae muscles?

A
  • Iliocostalis
  • Longissimus
  • Spinalis
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5
Q

How do spinal nerves exit the vertebral column?

A

Through intervertebral foramen

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6
Q

Where does the spinal cord end?

A

L1 as the conus medularis

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7
Q

What is a dermatome?

A

An area of skin that is mainly supplied by a single nerve

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8
Q

What is a myotome?

A

The group of muscles that a single spinal nerve innervates

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9
Q

What are the mytomes of the upper limb?

A
  • C5: Shoulder abduction (deltoid)
  • C6: Elbow flexion/wrist extension (biceps)
  • C7: Elbow extensors (triceps)
  • C8:Long finger flexors (FDS/FDP)
  • T1: Finger abduction (interossei)
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10
Q

What are the myotomes of the lower limb?

A
  • L2: Hip flexion (iliopsoas)
  • L3,4: Knee extension (quadriceps)
  • L4: Ankle dorsiflexion (tib ant)
  • L5: Big toe extension (EHL)
  • S1: Ankle plantar flexion (gastrocnemius)
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11
Q

What is the association between fractures/dislocations and spinal cord injuries?

A
  • 15% of people with a fracture/dislocation will have SCI

- Majority of people with SCI will have an accompanying column injury

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12
Q

What is the epidemiology of spinal cord injuries?

A
  • 1,000 SCI / year in the UK
  • 50,000 people in the UK living with paralysis
  • M>F
  • Peak 20-29yrs
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13
Q

What are the most common causes of SCI?

A
  • Falls
  • RTAs
  • Sports and recreational activities
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14
Q

How does a complete SCI present?

A
  • No motor or sensory function distal to lesion
  • No anal squeeze
  • No sacral sensation
  • ASIA Grade A
  • No chance of recovery
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15
Q

How do incomplete SCI present?

A
  • Some function is present below site of injury

- More favourable prognosis overall

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16
Q

Why can it not be determined if a SCI is complete or incomplete acutely?

A

Patient may be in spinal shock

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17
Q

What classification system is used in SCI?

A

Asia classification

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18
Q

What is grade A in the ASIA classification system?

A
  • Complete

- No sensory or motor function preserved in sacral segments S4-S5

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19
Q

What is grade B in the ASIA classification system?

A
  • Incomplete

- Sensory but not motor function preserved below the neurological level and extending through sacral segments S4-S5

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20
Q

What is grade C in the ASIA classification system?

A
  • Incomplete
  • Motor function preserved below the neurological level
  • Majority of key muscles have a grade <3
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21
Q

What is grade D in the ASIA classification system?

A
  • Incomplete
  • Motor function preserved below the neurological level
  • Majority of key muscles have a grade >3
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22
Q

What is grade E in the ASIA classification system?

A

Normal motor and sensory function

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23
Q

Give examples of patterns of SCI.

A
  • Tetraplegia/Quadriplegia
  • Paraplegia
  • Central Cord Syndrome
  • Anterior Cord Syndrome
  • Brown-Sequard Syndrome
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24
Q

How does tetraplegia/quadriplegia present?

A
  • Partial or total loss of use of all 4 limbs and the trunk
  • Loss of motor/sensory function in cervical segments of the spinal cord
  • Respiratory failure due to loss of innervation to the diaphragm (phrenic nerve C3-5)
  • Spasticity
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25
Q

What causes tetraplegia/quadriplegia?

A

Cervical fracture

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26
Q

What is spasticity?

A
  • Increased muscle tone due to an upper motor lesion
  • Affects spinal cord and above
  • Injuries above L1
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27
Q

How does paraplegia present?

A
  • Partial or total loss of use of the lower-limbs
  • Impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord
  • Arm function spared
  • Possible impairment of function in trunk,
  • Spasticity if injury of spinal cord
  • Bladder/bowel function altered
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28
Q

What causes paraplegia?

A

Thoracic and lumbar fractures

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29
Q

What is paraplegia associated with?

A

Chest or abdominal injuries

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30
Q

Give examples of partial cord syndromes.

A
  • Central cord syndrome
  • Anterior cord syndrome
  • Brown-Sequard syndrome
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31
Q

How does central cord syndrome present?

A
  • Weakness of arms > legs

- Perianal sensation & lower extremity power persevered

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32
Q

How does central cord syndrome occur?

A
  • Older patients (arthritic neck)
  • Can be caused by a low velocity fall in the elderly
  • Hyperextension injury
  • Centrally cervical tracts more involved
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33
Q

How does anterior cord syndrome present?

A
  • Damaged anterior spinal artery
  • Fine touch and proprioception preserved
  • Profound weakness
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34
Q

How can anterior cord syndrome occur?

A
  • Hyperflexion injury

- Anterior compression fracture

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35
Q

How can Brown-Sequard syndrome occur?

A
  • Hemi-section of the cord

- Penetrating injuries

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36
Q

How does Brown-Sequard syndrome present?

A
  • Paralysis on affected side (corticospinal)
  • Loss of proprioception and fine discrimination (dorsal columns)
  • Pain and temperature loss on the opposite side below the lesion (spinothalamic)
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37
Q

How are SCI managed?

A
  • Key to the management of a patient with SCI is to prevent a secondary insult.
  • Particularly in patients with incomplete injuries
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38
Q

What neuroprotective interventions are there following primary spinal injury?

A
  • In-field stabilisation
  • ATLS resuscitation
  • Pharmacological agents
  • Prompt medical/surgical care
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39
Q

How should spinal injuries be initially managed?

A

Airway (C-spine control)

Breathing

  • Ventilation and oxygenation
  • Concomitant chest injuries

Circulation

  • IV fluids
  • Consider neurogenic shock if low BP and HR, loss of sympathetic tone, vasopressors

Disability

  • Assess neurological function including PR and perinanal sensation
  • Log rolling
  • Document
40
Q

What are the features of spinal shock?

A
  • Transient depression of cord function below level of injury
  • Flaccid paralysis
  • Areflexia
  • Last several hours to days after injury
41
Q

What are the features of neurogenic shock?

A
  • Hypotension
  • Bradycardia
  • Hypothermia
  • Injuries above T6
  • Secondary to disruption of sympathetic outflow
42
Q

What imaging should be used for spinal injuries?

A
  • X-ray
  • CT scanning for bony anatomy
  • MRI if neurological deficit or in children
43
Q

When is surgical fixation used?

A

In the case of unstable fractures

44
Q

How is surgical fixation carried out?

A
  • Vast majority fixed from posteriorly

- Pedicle screws preferred method

45
Q

What is the long term management for spinal injuries?

A
  • Spinal Cord Injury Unit- intermediate term
  • Physiotherapy
  • Occupational therapy
  • Psychological support
  • Urological /Sexual counseling
46
Q

What gets compressed in a lateral disc protrusion of the lumbar region?

A

Nerve roots

47
Q

What gets compressed in a central disc protrusion of the lumbar region?

A

Cauda equina

48
Q

What type of joint is the interevertebral disc?

A

Secondary cartilaginous

49
Q

What is the structure of the intervertebral disc?

A
  • Largest avascular structure in the body
  • Tough outer layer= annulus fibrosus (fibres run obliquely and alternate between layers)
  • Gelatinous core= nucleus pulposus
50
Q

What type of injury can occur at the intervertebral discs?

A

Annulus may tear and nucleus may prolapse

51
Q

How are the intervertebral discs connected to the vertebral bodies?

A

By the ALL and the PLL

52
Q

What types of movement do the intervertebral discs resist?

A

Rotational movements

53
Q

What are the most common types of disc prolapse?

A

Postero-lateral

54
Q

What does the nucleus pulposus consist of?

A
  • Mainly water 88%
  • Collagen
  • Proteoglycans (very hydrophilic)
55
Q

What occurs during the normal ageing process in regards to the intervertebral discs?

A
  • Decreased water content of discs
  • Disc space narrowing
  • “Degenerative” changes on X-rays
  • Degenerative changes in the facet joints
  • Aggravated by smoking, etc.
56
Q

What pathological processes can occur with the intervertebral discs?

A
  • Tearing of annulus fibrosis and protrusion of the nucleus
  • Nerve root compression by osteophytes
  • Central spinal stenosis
  • Abnormal movement(spondylolysis, spondylolisthesis)
57
Q

How does nerve root pain present?

A
  • Fairly common
  • Limb pain worse than back pain
  • Pain in a nerve root distribution (radicular)
  • Root tension signs
  • Root compression signs
  • Dermatomes & myotomes
58
Q

How should nerve root pain be managed?

A
  • Most will settle, about 90% in 3 months
  • Physiotherapy
  • Strong analgesia
  • Referral after 12 weeks
  • Imaging including MRI
59
Q

Name 4 disc problems

A
  • Bulge
  • Protrusion
  • Extrusion
  • Sequestration
60
Q

What is a disc bulge?

A
  • Generalised
  • Common and majority asymptomatic
  • Small ‘bump’
61
Q

Why is a disc protrusion?

A

Annulus is weakened but still intact

62
Q

What is disc extrusion?

A

Nucleus pushes through annulus but continuity

63
Q

What is disc sequestration?

A

Desiccated disc material is free in the canal

64
Q

Where is the most common site of cervical disc prolapse?

A

C5/6

65
Q

Where do thoracic disc prolapses occur?

A
  • <1% of intervertebral disc prolapses
  • Mid to lower levels (75% T8-12)
  • Most at T11/12
  • Central, posterolateral and lateral herniations
66
Q

Where do lumbar disc prolapses occur?

A
  • Usually L4/5 (45%), followed by L5/S1 (40%), then L3/4 (10%)
  • Most are posterolateral (Posterior Longitudinal Lig weakest)
  • Central disc may give pain in both legs, or may be back pain only
67
Q

How will a prolapsed disc at L5/S1?

A

Nerve root
-S1

Sensory loss
-Little toe and sole of foot

Motor weakness
-Plantar flexion of foot

Reflex change
-Ankle jerk

68
Q

How will a prolapsed disc at L4/L5?

A

Nerve root
-L5

Sensory loss
-Great toe and 1st dorsal web space

Motor weakness
-EHL

Reflex change
-None

69
Q

How will a prolapsed disc at L3/L4?

A

Nerve root
-L4

Sensory loss
-Medial aspect of lower leg

Motor weakness
-Quads

Reflex change
-Knee jerk

70
Q

What is cauda equine syndrome?

A

A surgical emergency where the cauda equine is compressed

71
Q

What can compression of the sacral nerve roots result in?

A

Permanent bladder and anal sphincter dysfunction with incontinence

72
Q

What should be done if someone presents with suspected cauda equine syndrome?

A
  • Admission
  • Urgent MRI scan
  • Emergency operation within 48 hr of onset
  • Delay results in permanent dysfunction
73
Q

What is the aetiology of cauda equine syndrome?

A
  • Central lumbar disc prolapse (commonest)
  • Tumours
  • Trauma (burst or Chance #, disc) or spinal stenosis
  • Infection (epidural abscess)
  • Iatrogenic (spinal surgery or manipulation, spinal epidural injection)
74
Q

What are the clinical features of cauda equine syndrome?

A
  • Injury or precipitating event
  • Bilateral buttock and leg pain with vary dysesthesia and weakness
  • Bowel or bladder dysfunction (urinary retention+/- incontinence overflow)
  • Saddle anaesthesia , loss of anal tone and anal reflex
75
Q

When should you have a high index of suspicion for cauda equine syndrome?

A

Spinal post-op patients with increasing leg pain in presence of urinary retention

76
Q

What radiological images should be taken in suspected cauda equine?

A
  • MRI

- Lumbar CT myelogram (if MRI contraindicated)

77
Q

What is the treatment for cauda equine syndrome?

A

OPERATIVE

-Within 48 hours

78
Q

What are the possible outcomes of cauda equine syndrome?

A
  • 30% undergoing discectomy for cauda equina syndrome did NOT regain normal urinary function
  • 25% with motor deficits never regained full power
  • 33% with sensory deficits never regained normal sensation
  • 25% with perianal paraesthesiae did not return to normal
  • 26% had persitent sexual dysfunction
79
Q

What are cervical and lumbar spondylosis?

A

Common degenerative change which occurs at the facet joints, discs, ligaments etc. of the spine

80
Q

What can happen in severe spondylosis?

A

Can compress the whole cord causing myelopathy

-UMN signs in limbs

81
Q

What type of movement do the synovial facet joints of the spine allow?

A

Mainly flexion and extension

82
Q

What ligaments are there in the spine?

A
  • Anterior longitudinal ligament
  • Posterior longitudinal ligament
  • Ligamentum flavum
  • Interspinous and supraspinous ligaments
  • Intertransverse ligament
83
Q

Where does the anterior longitudinal ligament run?

A

Along the front of the vertebral bodies

84
Q

Where does the posterior longitudinal ligament run?

A

Along the backs of the vertebral bodies

85
Q

Where does the ligamentum flavum run?

A

Between the lamina

86
Q

Where does the interspinous and supraspinous ligaments run?

A

Between the spinous processes

87
Q

Where does the intertransverse ligament run?

A

Between the transverse processes

88
Q

What is lumbar spondylosis?

A

OA of facet and disc joints (+ degeneration of ligaments etc.)

89
Q

How is spinal claudication distinguished from vascular claudication?

A
  • Usually bilateral
  • Sensory dysaesthesiae
  • Poss weakness (drop foot – tripping)
  • Takes several minutes to ease after stopping walking
  • Worse walking down hills because the spinal canal becomes smaller in extension, better walking uphill or riding bicycle
90
Q

Give examples of types of spinal stenosis.

A
  • Lateral recess stenosis
  • Central stenosis
  • Foraminal stenosis
91
Q

What is the treatment for lateral recess stenosis?

A
  • Non-operative
  • Nerve root injection
  • Epidural injection
  • Surgery
92
Q

What is the treatment for central stenosis?

A
  • Non-operative
  • Epidural steroid injection
  • Surgery (80% improve)
93
Q

What is important in central stenosis cause?

A

The shape of the canal (congenital)

94
Q

What is the treatment for foraminal stenosis?

A
  • Non-operative
  • Nerve root injection
  • Epidural injection
  • Surgery
95
Q

What do the symptoms of spondylolisthesis vary with?

A

Type of spondylolisthesis

96
Q

What is the treatment for spondylolisthesis?

A

Treatment depends on symptoms

  • Conservative with lifestyle changes
  • Surgery for persistent pain +/- nerve root entrapment

Systems: MSK AB (43 decks)

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