The Spine Flashcards
Define radiculopathy & radicular pain
Conduction block in axons of spinal nerve or its roots -> impact motor axons - weakness + sensory - paraesthesia/ anaesthesia
State of neurological loss & may be associated with radicular pain (derived from damage/ irritation spinal nerve tissue particularly DRG)
Aetiology of radiculopathy
Most commonly due nerve compression, caused by:
- intervertebral disc prolapse
LS mostly, repeated minor stresses predispose rupture annulus fibrosus & sequestration of disc material (nucleus pulposus)
- degenerative diseases spine -> neuroforaminal or spinal canal stenosis
CS most mobile, 80% >55yrs degenerative changes C5/6 & C6/7 - fracture
- malignancy (most metastatic)
- infection
Extradural abscesses, oesteomyelitis (TB - Pott’s disease), herpes zoster
Clinical features of radiculopathy & red flags
Sensory features (paraesthesia numbness)
Motor features (weakness)
Radicular pain (burning, deep, strap-like, narrow, can be intermittent)
Identify dermatomal & myotomal involvement
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Faecal incontinence, urinary retention, saddle anaesthesia, pinprick sensation reduced perianal dermatomes, diminished anocutaneous reflex, reduced anal tone, reduced rectal pressure sensation - CES
Immunosuppression, IV drug, unexplained fever - infection
Chronic steroid - fracture/ infection
Significant trauma, oesteoporosis/ metabolic bone disease - fracture
New onset after 50yrs - malignancy
History malignancy - metastic disease
Differentials for radiculopathy
CES Infection Fracture Malignancy Referred pain (MI, hepatobiliary, urinary tract) Myofascial pain (hip muscles) Thoracic outlet syndrome Greater trochanteric bursitis Iliotibial band syndrome Meralgia paraesthetica Piriformis syndrome
What are some neuropathic pain medications
WHo analgesia pain ladder
->
Amitriptyline 1st line
GABA antagonists (pregabalin, gabapentin)
Muscles spasms - benzodiazepines (diazepam) / baclofen
The spinal cord tapers to an end - what is the term for this? Where does this occur? What does it become?
Conus medullaris
L1
L1-S5 nerve roots leave - cauda equina
Lower motor neurones - motor, sensory LL, motor anal sphincters, parasympathetic bladder
How many of each section of vertebral column are there?
C 7 T 12 L 5 S 5 Coccyx
Causes of CES
Disc herniation - mostly L5/S1, L4/L5
Trauma (fracture, subluxation)
Neoplasm (thyroid, breast, lung, renal, prostate)
Infection (discitis/ Pott’s disease)
Chronic spinal inflammation (anklyosing spondylitis)
Iatrogenic (haematomma post anaesthesia)
Clinical features of CES
Lower motor neurone signs & symptoms
Reduced LL sensation (often bilateral) Bladder/ bowel dysfunction LL weakness Severe back pain Impotence Saddle anaesthesia Hypoflexia
Urinary retention
Post-void Bladder scan - suspicion 200ml retention post voiding
PR examination
40-50yrs
Classification CES
- CES with retention - back pain, un/bilateral sciatica, Ll weakness, sensory disturbance saddle, loss anal tone, loss urinary control
- Incomplete CES - as above but only altered urinary sensation, painful retention may precede painless retention
(Greater potential neurological recovery) - Suspected CES - severe back & leg pains, variable neurological symptoms & signs, sphincter disturbance
Most progressive
CESR
CESI
CESS
Investigations & management for CES
Investigations:
Emergency Whole spine MRI ⭐️ 60% suspected will have abnormality
May have further imaging
Management:
Early neurosurgical review for urgent decompression
✅high dose steroids (dexamethasone) reduce swelling
✅ immobilisation if trauma
✅surgical decompression
✅radio/chemoT - malignancy
Which is not a feature of CES: hypotonia, spastic paralysis, hyporeflexia, downgoing plantars?
Spastic paralysis
Causes of the surgical emergency acute spinal cord compression
Metastatic spinal cord compression (MSCC) most common - neoplastic (thyroid, lung, breast, renal, prostate), primary bone tumours, haematological - myeloma
Traumatic - fracture/ facet joint dislocation
Infective - abscess (TB, fungal)
Disc prolapse - rare (typically lumbar - CES)
Predispose:
- RA -anklyosising spondylitis - ligamentum flavum hypertrophy - osteophyte
Clinical features of spinal cord compression
Sensation/ proprioception impaired dermatomes below
Pain - aggravated straining
Bi/unilateral weakness
UMN signs (hypertonia, hyperreflexia, Babinski’s sign, clonus)
Reflexes absent level of lesion - LMN in VH compressed
Autonomic involvement - late stage e.g. bowel incontinence, constipation, urinary retention
Differentials for spinal cord compression & investigations
Lumbago - pain solely Lower lumber area with no radiation, sciatica, lower back pain -> buttocks/ LL - often caused disc herniation pressing exiting nerve -> LMN signs
CES - lumbar disc herniation
Investigations:
⭐️ MRI whole spine
Routine bloods (G&S, clotting)
