1
Q
Remind yourself of the structure of the roots of spinal nerves
A
2
Q
Remind yourself of the structure of intervertbral discs
A
- Annulus fibrosis= shock absorber of spine. Made of annular bands of collagen in varying orientations. Avascular & aneural.
- Nucleus pulposus= remnant of notochord. Gelatinous and consists of type 2 collagen. Gradually decreases in height during day as water is squeezed out due to mechanical pressure. Also decreases in height with age.
3
Q
Remind yourself how to differentiate between the different vertebrate
A
4
Q
Remind yourself of the myotomes
A
5
Q
Remind yourself of the dermatomes
A
6
Q
Remind yourself of the peripheral nerve distribution in the upper limb
A
7
Q
Remind yourself of sensory distribution of nerves in lower limb
A
8
Q
Define dermatome
Define myotome
A
- Dermatome= area of skin supplied by a single spinal nerve
- Myotome= group of muscles supplied be a single spinal nerve
9
Q
Define radiculopathy
A
Conduction block in axons of spinal nerve or it its root; results in weakness (when impacts of motor neurones) and parasthesia or anaesthesia (when impacts on sensory neurones)
10
Q
Define myelopathy
A
Myelopathy is neurological signs & symptoms due to pathology of the spinal cord
*NOTE: must be compressing spinal cord e.g. therefore not cauda equina
11
Q
Define radicular pain
A
Radicular pain= pain deriving from damage or irritation of the spinal nerve tissue- particularly dorsal root ganglion
*NOTE: different from radiculopathy wich can be thought of as a state of neurologial loss and may or may not be associated with radicular pain
12
Q
What scale is used for neurologic classification of spinal cord injury?
A
ASIA impairment scale (American Spinal Injury Association Impairment Scale). Divides spinal cord injuries into 5 categories:
- Complete
- Incomplete sensory
- Incomplete motor (muscle grade below 3)
- Incomplete motor (muscle grade 3 or above)
- Normal
13
Q
State some potential causes of radiculopathy
A
Most commonly a result of nerve compression which can be due to:
- Intervertebral disc prolapse (lumbar spine most common)
- Degenerative diseases of spine which lead to neuroforaminal or spinal canal stenosis (cervical spine most common as it is most mobile)
- Fracture (trauma or pathological)
- Malignancy (most commonly metastatic)
- Infection (e.g. extradural abscesses, osteomyelitis, herpes zoster)
14
Q
Describe clinical features of radiculopathy
A
- Sensory features: parasthesia, numbness
- Motor features: weakness
- Radicular pain (deep, burning, strap like pain. Can be intermittent)
- Red flag symptoms
15
Q
State the red flags for:
- Cauda equina
- Infection
- Fracture
- Malignancy/metastatic disease
A
Cauda Equina
- Bilateral sciatica
- Neurological deficit of legs e.g. motor weakness
- Saddle anaesthesia
- Painless urinary retention
- Erectile dysfunction
- Faecal & urinary incontinence
Infection
- Immunsupression
- IV drug use
- Unexplained fever
- Diabetes
- TB or recent UTI
Fracture
- Significant trauma
- Osteoporosis or metabolic bone disease
- Chronic steroid use (oral steroids =/3 months)
Malignancy/metastatic disease
- History of malignancy
- New onset over 50yrs
- Night pain that disturbs sleep (suggest pain not mechanical/not due to axial loading as pain occuring when supine and spine is not loaded)
*NOTE: be concerned about age <18yrs and >55yrs. Be concerned about thoracic pain as thoracic spine is least mobile so unlikely to be mechanical.
16
Q
What must you ensure you examine in anyone presenting with symptoms of radiculopathy
A
- Pin prick sensations all dermatomes
- Motor function (Oxford muscle grading)
- Assess pin prick sensaton in perianal dermatomes (reduced in CES)
- Anocutaneous reflex (diminished or absent in CES)
- Anal tone (reduced in CES)
- Catheter tug (if catheter in situ. Tug catheter and ask pt if they can feel it. Reduced or absent in CES)
- Bladder scan (pre- and post-void. If 200mL or moer= retention)
- Consdier rectal pressure sensation
17
Q
What is the anocutaenous reflex/how do you assess it?
A
anocutaneous reflex is assessed by means of stimulation with pinprick in the perianal region, which leads to visible reflexive anal contraction
18
Q
How do you assess anal tone?
A
Ask pt to squeeze anus whilst doing DRE and assess for tone. Can also ask to cough and anal tone should increase.
19
Q
State some differential diagnosis for radicular pain
A
Differential diagnoses inlcude pseudoradicular pain syndromes (conditions that do not arise due to nerve root dysfunction but cause radiating limb pain in an radicular pattern):
- Referred pain
- Myofascial pain
- Thoracic outlet syndrome
- Greater trochanter bursitis
- Iliotibial band syndrome
- Meralgia parasthetica
- Piriformis syndrome
20
Q
What is myofascial pain?
A
- Hip muscles can mimic pain from lumbar radiculopathy
- Shoulder girdle muscles can produce pain radiating to upper extremity
- Examine for tenderness at specific muscle sites which when palpated produce radiating pain
21
Q
What is meralgia parasethetica?
A
- Compression of lateral femoral cutaenous nerve of thigh as it passes under inguinal ligament.
- Presents with clearly demarcated area of parasthesia and/or numbness in anterolateral aspect of thigh
22
Q
Discuss the general principles of the management of radiculopathy
A
- Depends on underlying cause.
- Main one to identify quickly/rule out is CES as it requires emergency surgical treatment.
23
Q
What age group is cauda equina syndrome common in?
A
- 30-50yrs
24
Q
What is the commonest cause of CES?
A
slipped disc that fills the spinal canal (2% of all disc prolapses we see)
25
What is the management of CES?
Emergency surgical decompression within 24-48hrs of onset of sphincter symptoms thorugh laminectomy or discectomy
26
State some potential complications of cauda equina *(and suggest how we can help pts to manage these complications)*
* **Motor weakness dependent on which nerves affected- not necesarily paralysis!** E.g. if L4/L5: L3 and L4 intact
* **Bladder & bowel incontinence** *(Can't feel bladder filling so get pt to intermittently self-catheterise to empty bladder. Or indwelling suprapubic catheter. Empty bowels by clock, colonic lavage, colostomy)*
* **Sexual dysfunction**
27
Discuss the symptomatic management of radiculopathy
* Analgesia- in particular neuorpathic pain medications e.g.
* Amitriptyline
* Pregabalin
* Gabapentin
* Medication for muscle spasms e.g.
* Benzodiazepines
* Baclofen
* Physiotherapy
28
What is meant by degenerative disc disease?
Natural deterioration of intervertebral disc structure in which disc becomes progressively weak and begins to collapse. Many remain asymptomatic but some develop pain & further complications
29
State some risk factors for degenerative disc disease
* Age
* Progressive dehydration of nucleus pulposus
* Daily activities tear annulus fibrosis
* History of injury or pathology
* Spinal fractures
* Iatrogenic injuries
30
Outline the three stages of degenerative disc disease
1. **Dysfunction:** outer annulus tears, separation of end plate, cartilage destruction, facet synovial reaction. Unlikely to feel pain at this stage; maybe some discomfort and changes to posture
2. **Instability:** disc resorption and loss of disc space height, facet capsular laxity which can lead to subluxation and spondylolisthesis. Experience aches, pains & fatigue.
3. **Restabilisation:** degenerative changes lead to osteophyte formation & spinal canal stenosis. Pain due to compression of nerve roots. Fatigued.
31
Describe clinical features of disc degeneration
Symptoms depend on region & severity of disease.
* _Early stages:_ symptoms often localised and have unremarkable clincial exmaination. May have local spine tenderness, contracted paraspinal muscles, hypomobility, painful extension of the back or neck.
* _Late stages:_ increasing pain- may have radicular pain and parasthesia also. Pain reproduced by passively raising extended leg (Lasegue sign). Worsenign muscle tenderness, stiffness, decreased ROM, scoliosis
32
What test can be done to assess for radicular pain caused by disc herniation?
* Lasègue test (straight leg raise test)
* To determine whether a patient with low back pain has an underlying herniated disk, often located at L5 (fifth lumbar spinal nerve).
How to perform:
* Pt lying supine
* Lift leg whilst knee is extended (ankle can be dorsiflexed for fruther assessment)
* Positive sign when leg raising +/- dorsiflexion causes pain (between 30-70 degrees)
33
Diagnosis of degenerative disc disease is largely clinical; state some circumstances in which you would consider imaging
NICE suggests imaging only warranted in cases of suspected disc degenerative disease if:
* Red flags present
* Radiculopathy with pain for \>6 weeks
* Evidence of spinal cord compression
* Imaging would significantly alter management
Spine radiographs only reccommended if pt has history of significant recent trauma, known osteoporosis or is \>70yrs.
MRI spine= gold standard for suspected degenerative disc disease. BUT majority don't require imaging.
Lecturer said only consider imaging if pain \>3 months (so long as no red flags)
34
What might you see on MRI if degenerative disc disease is present?
* Reduced disc height
* Annulus tears
* Endplate changes
* Osteophytes
35
Discuss the management of degnerative disc disease
VARIABLE & PATIENT DEPENDENT!
* Analgesia (simple as first line, neuropathic adjuncts if required)
* Encouraging mobility
* Physiotherapy to strengthen muscles
* Referral to pain clinic if necessary
*\*Surgery only required if cases of CES*
36
What is the difference between degenerative disc disease and disc herniation?
Degenerative disc disease takes time the disc is just wearing out, losing the water and gel components that support your back overtime. Herniated disc is where the content is still there it is not drying out it just bulging and causing sometimes a different type of pain
37
State some risk factors for disc hernation
* Age
* Heavy lifting (particularly with improper form)
* Obesity
* Sedentary lifestyle
* Male
38
Outline the stages of disc hernation
1. **Disc degeneration:** *chemcial changes associated with ageing cause discs to dehydrate and bulge*
2. **Prolapse**: *protrusion of nucelus pulposus with slight impingment into spinal canal. Nucleus pulposus still contained in annulus fibrosus.*
3. **Extrusion:** *nucleus pulposus breaks through annulus fibrosus but it still contained within disc space*
4. **Sequestration**: *nucleus pulposus separates from main bdoy of disc and enters spinal canal*
39
Which discs are at greatest risk of herniation?
* L4/L5
* L5/S1
due to mechanical loading!
40
Which nerve roots are affected in:
* Central
* Paracentral
* Far lateral
... disc herniations
* Central: can compress spinal cord therefore risk of CES
* Paracentral *(posterolaterally)*: traversing nerve
* Far lateral: exiting nerve root
Remember the exiting nerve root is root that emerges at same level as intervertebral disc. Traversing nerve root is one that is exiting at level of next intervertebral disc. Nerve root emerges above level of that disc e.g. L4 nerve root emerges above the level of L4/L5 disc.
E.g. *if disc herniation of L4/L5 disc:*
* *Paracentral: L5 compression*
* *Far latera: L4 compression*
41
What investigations are required if you suspect disc herniation?
* Mostly clincial diagnosis
* May request MRI
42
Discuss the management of disc herniation
Most manged non-operatively and resolve themselves in a few months. Non-operative management includes:
* Analgesia e.g. NSAIDS & paracetamol (neuropathic adjuncts if necessary)
* Encourage mobility
* Physiotherapy
Surgical intervention may be considred if there is unremitting pain despite non-operative mangement, progressive weakness or new or progressive myelopathy
43
Which vertebrate of spine are commonly fractured?
C2 (30%)
C7 (20%)
44
The AO classification system is most commonly used for cervical fractures. There is a different AO classification for upper cervical fractures (C1 or C2) and subaxial (below C2) fractures.
Describe the AO classification for upper cervical fractures
45
The AO classification system is most commonly used for cervical fractures. There is a different AO classification for upper cervical fractures (C1 or C2) and subaxial (below C2) fractures.
Describe the AO classification for subaxial fractures
46
Describe the clinical features of cervical fractures
* History high energy trauma (young)
* History of low energy trauma (old)
* Neck pain (not always present!!!)
* Neurological involvement
* Sensory or motor deficits
* Breathing difficulites (if innervation to diaphragm disrupted)
* Vasomotor tone affected
* Posterior circulation stroke (if injury to vertebral artery)
47
There are 3 eponymous fractures of the cervical spine; state these
* Jefferson fracture
* Hangman's fracture
* Odontoid peg fracture
48
For a Jefferson fracture, discuss:
* What it is
* Mechanism of injury
* Stable or unstable
* Neurological signs?
* Burst fracture of the atlas (C1)
* Axial loading of cervical spine resulting in occipital condyle being driven into lateral masses of C1
* Usually unstable
* 'Bursting open' of fracture reduces likelihood of impingement to spinal cord therefore typically no neurological signs
49
For a Hangman's fracture, discuss:
* What it is
* Mechanism of injury
* Stable or unstable
* Any neurological signs?
* Fracture through pars interarticularis of C2 bilaterally (also called traumatic spondylolisthesis of the axis)
* Cervical hyperextension
* Can be unstable
* Tends to expand spinal canal therefore reducing risk of associated spinal injury
*\*Pars interarticularis is region between superior and inferior articulatar processes*
50
For odontoid peg fractures, discuss:
* What it is
* Who common in
* Fatality?
* Fracture of odontoid peg
* Common in elderly
* Can be fatal; those who survive often have no neurology
51
What does image A show?
What does image B show?
* A= CT scan of jefferson fracture
* B= plain fim radiograph of Hangman's fracture
52
What rules can be used to risk stratify a pt with risk of cervical apine injury and hence help you determine what imaging is required?
Canadian C spine rules
53
If you suspect a cervical spinal fracture what imaging would you do
* **CT for adults** if Canadian C-spine suggests appropriate
* **MRI for children** if Canadian C-spine suggests appropriate
* Consider plain fim radiograph for children who don't meet full MRI criteria but suspiscion remains
54
Discuss the manaagement of suspected cervical fractures, include:
* Initial management
* Definitive management
_Immediate Management_
* **ATLS**
* Including 3 point C spine immobilisation
* Discussion with spinal specialist
* ASIA chart to assess for spinal injuries
_Definitive management_
* Stable injuries or those who are not fit for operative mangement= non-operative
* Halovests
* Traction devices
* Unstable injuries = operative
* Fuse injured segment of spine to uninjured segments above and below with or without decompression of vertebra lcanal
55
Where do spinal fractures tend to occur?
Zones of mechanical transition
56
We often refer to the spine consisting of three columns; state these three columnds
57
Thoracolumbar fractures can be classified based on their morphology according to AO classification; there are three categories A, B and C. Describe each
* A= compression injury
* B= disraction injury
* C= translation injury
58
What is a burst fracture?
* Compressive force acts through anterior & middle columns of spine
* Retropulsion of bone into spinal canal
* Can invovle one end plate (incomplete burst) or both endplates (complete burst)
* Can result in spinal cord injury
59
What is a chance fracture?
* Result from excessive flexion of spine
* Involve all 3 columns
* Unstable & need surgical intervention
* Classically occur fllowing head on RTA in which pt only wearing lap belt
60
State some clinical features of thoracolumbar fractures
* Back pain (may not always be present if there are other distracting injuries)
* Neurological involvement
* Sensory deficits
* Motor deficits
61
What investigations may you do if you suspect a thoracolumbar fracture?
* **Plain film radiograph AP & lateral** (if no signs of spinal cord injury)
* **CT scan** (if radiograph abnormal or signs of spinal cord injury)
* **If new spinal column fracture identified, image rest of column**
* **MRI for soft tissue**
62
Discuss the management of thoracolumbar fractures, include:
* Immediate
* Definitive
_Immediate_
* ATLS
* Immobilisation of spine
_Definitive_
* Stable= non operative
* Extension bracing & lumbar corsets
* Physiotherapy
* Non-stable= operative
* Decompression & spinal fusion and fixation
63
What scoring system can be used to help you assess likelihood of thoracolumbar injury?
TLIC (thoraco-lumbar injury classification & severity) scoring system
*\*Looks at morphology, integrity of posterior ligamentous complex and neurological status*
64
Myelopathy commonly affects cervical spine. For cervical myelopathy discuss:
* Who common in
* Common cause
* Symptoms
* Management
* **Elderly \>65yrs**
* **Commonly due to OA** in cervical spine resulting in osteophytes and thickening of ligamentum flavum
* Symptoms- get progressively worse:
* Pain in neck, may radiate down arm
* Stiffness
* Tenderness over spine
* Paraesthesia in upper limbs (commonly hands)
* Loss of fine motor movements e.g. can you do buttons up? Can you use knife and fork like you usually would/used to?
* Balance- often stagger like drunk
* Requires **operative management** as otherwise lose independence and there is no conservative management. Can guarantee that symptoms wont’ get worse than what they are but can’t guarantee that they will regain function.
65
Remind yourself of management of mechanical back pain from GP block
* Lifestyle:
* Exercise core muscles
* Physiotherapy
* Low impact activities
* Avoid activities such as running, jumping etc… If want to run, run on softer surfaces or a treadmill
* Weight loss
* Postural adaptations e.g. particularly at work (back rests, foot stools etc…)
* Hot water bottle/heat pack
* Pharmacological:
* Simple analgesia: paracetamol & NSAIDs (e.g. ibuprofen), co-codamol
66
What is sciatica?
What are the nerve roots of the sciatic nerve?
State some common causes
* Irriation or compression of sciatic nerve
* L4-S3
* Causes:
* Slipped disc
* Marginal osteophytosis
* Piriformis syndrome
* Lumbar spinal stenosis
* Pregnancy
* Back injury
67
State symptoms & signs of sciatica
* Pain: sharp, shooting, burning pain that radiates from back down to the affected dermatome e.g.
* L4 sciatica: anterior thigh, anterior knee, medial leg
* L5 sciatica: lateral thigh, lateral leg, dorsum of foot
* S1 sciatica: posterior thigh, posterior leg, heel, sole of foot
* Parasthesia in AFFECTED DERMATOME ONLY
* Positive straight leg test
68
Discuss whether you would do any investigations for sciatica
Most people better in 6-8weeks as body breaks down the disc, relieves pressure on nerve root, stop sciatica. Therefore review in about 8 weeks and if pain not improved consider MRI scan
69
Discuss the management of sciatica
* **May need short period of bed rest e.g. 2-3 days but they must then stay active & mobile within limits**
* **Analgesia:**
* NSAIDs
* Codeine based opiates e.g. co-codamol
* Neuropathic pain medication e.g. amitriptyline, gabapentin, pregabalin
* *Cosnider benzodiazpeines - muscle relaxants*
* **Injection of local anaesthetic & corticosteroid:**
* **Nerve root block:** under x-ray control guide needle down to where nerve irritation is and inject into sheath surrounding affected nerve.
* Epidural- rarely give in ortho
* **Surgery: lumbar dissectomy**
*Review in ~8 weeks; do MRI scan to investigate further if no improvement. Physiotherapy only useful once sciatica started getting better (e.g. after 6-8 weeks) to strengthen muscles & posture to prevent further disc prolapse in future*
70
Discuss the role of physiotherapy in sciatica
Physiotherapy only useful once sciatica started getting better (e.g. after 6-8 weeks) to strengthen muscles & posture to prevent further disc prolapse in future
71
For UMN state:
* Where pathology is
* Signs
* Pathology in brain or spinal cord
* Signs:
* Hypereflexia
* Hypertonia
* Extensor plantar reflexes
* Clonus
* Hoffman's sign
72
For LMN state:
* Where pathology is
* Signs
* Pathology in ventral horns, spinal nerves or peripheral motor nerves
* Signs:
* Weakness
* Areflexia/hyporeflexia
* Wasting
* Hypotonia
* Fasciculations
73
What is clonus?
* Neurological condition that creates rhythmic, involuntary muscle contractions.
* Relax the ankle by gently rotation then suddenly dorsiflex ankle. If foot oscillates between plantar flexion and dorsiflexion this is clonus. All of us have ‘ a couple of beats’; pathological clonus need \>5 beats
74
What is Hoffman's sign, include:
* What it is used to test for
* How to perform
* Positive sign
* Used to determine UMN above T1/in cervical spine
* Get pt to put hand in dosriflex position with fingers slightly flexed. Hold middle finger at proximal IP joint and flick middle finger and observe movements of thumb and index finger
* Positive result:
* Flexion of IPJ of thumb
* Flexion of DIPJ of index finger
75
What investigations should you do if pt has spinal metastasis?
* Bloods
* FBC
* U&Es
* Serum calicum
* Clotting screeen
* MRI whole spine
* Staging CT of chest, abdo & pelvis
* Myeloma screen & other tumour markers
76
Discuss the management of spinal metastasis
* Dexamethasone (16mg daily)
* Keep pt supine if spine unstable
* Surgery indicated for:
* Stabilising spine
* Decompress spinal cord
* Relieve pain from mechanical instability
77
Where in spine do spinal infections commonly affect?
What is most common cause of spinal infections worldwide?
* Vertebral end plate, adjacent disc and vertebral body
* TB (Pott's disease of spine/tuberculosis spondylitis)
* *Staphylococcus aeurus= commonest non-TB infective organism*
78
Diagnosis of spinal infection is often delayed; true or false?
True (average diagnosis 12 weeks later)
79
What investigations are required if you suspect spinal infection?
* Routine bloods
* Blood culture
* Sputum samples, CXR if thinking Potts disease of spine
* Needle biopsy of IV disc
80
Discuss the management of spinal infections
* IV abx for 6-12 weeks in non-TB
* IV abx for 6-12 months in TB
* Surgery indicatd if:
* CES
* To drain paravertebral abscess
* To restore mechanical mobility
