Orthopaedics - spine Flashcards
Radiculopathy
Conduction block in the axons of a spinal nerve or its roots
State of neurological loss and may/may not be associated with radicular pain (radicular pain = pain deriving from damage/irritation of the spinal nerve tissue, particularly the dorsal root ganglion)
Radiculopathy aetiology
Most commonly a result of nerve compression, which can be caused by:
- Intervertebral disc prolapse
- Degenerative diseases of the spine
- Fracture
- Malignancy
- Infection
Radiculopathy clinical features
Sensory features – paraesthesia and numbness
Motor features – weakness
Radicular pain is often also present – typically described as a burning, deep, strap-like or narrow pain
Red flag symptoms should be asked about
Examination – important to identify dermatomal and myotomal involvement, ensure to evaluate for cauda equina syndrome
Radiculopathy management
Definitive long-term management depends on the underlying cause
Most IV disc prolapses can be managed non-operatively
Symptomatic management
- Analgesia: WHO analgesia can be used, however neuropathic pain medications are frequently utilised
- Amitriptyline: usually first line or pregabalin/gabapentin as alternatives
- Physiotherapy: remains an important part of management in this patient group
Cervical fracture clinical features
Neck pain
Varying degrees of neurological involvement present, depending on the level of spinal cord involvement
Any injury to the vertebral artery from a cervical fracture may present with a posterior circulation stroke
Jefferson fracture
Given to a burst fracture of the atlas
It is caused by axial loading of the cervical spine resulting in the occipital condyles being driven into the lateral masses of C1
Often associated with head injuries and other concurrent cervical spinal injuries
Hangman’s fracture
Traumatic spondylolisthesis of the axis, describes a fracture through the pars interarticularis of C2 bilaterally, usually unstable & account for approximately a third of all C1 fractures
Caused by cervical hyperextension and distraction
Can be unstable, in such cases, surgical fixation will be required
Odontoid peg fractures
Common cervical fractures, most common in older patients
Can present following low-impact injuries, neck pain being common
Condition can be fatal, esp. significant displacement of the odontoid
Those who survive can have no neurology
Cervical fractures investigations
CT scan in adults
MRI for children
Only consider a plain film radiograph in children for those who do not fulfil the criteria
Cervical fractures management
Patients with a suspected cervical fracture including 3-point C-spine immobilisation
Restricting movement of the spine is recommended to prevent potential damage to the spinal cord – movement at the level of an unstable fracture can cause further neurological deficit
Non-operative management can be appropriate for stable injuries:
- Rigid collars
- Halo vests are used when more rigid support is needed
Traction devices can be used for definitive treatment when operative treatment is high risk
Operative management – unstable fractures
Degenerative disc disease
Natural deterioration of the intervertebral disc structure, such that they become progressively weak and begin to collapse
Degenerative disc disease pathophysiology
1) Dysfunction – outer annular tears and separation of the endplate, cartilage destruction and facet synovial reaction
2) Instability – disc resorption and loss of disc space height, along with facet capsular laxity, can lead to subluxation and spondylolisthesis
3) Restabilisation – degenerative changes lead to osteophyte formation and canal stenosis
Degenerative disc disease clinical features
Early stage disease symptoms are often localised and clinical examination may be unremarkable
Potential signs – local spinal tenderness or contracted paraspinal muscles, hypomobility or painful extension of the back or neck
All cases require a complete neurological examination
Pain may be reproduced by passively raising the extended leg (positive Lasegue sign)
Degenerative disc disease investigations
Imaging should only be warranted in cases of suspected degenerative disc disease if:
1) Red flags present
2) Radiculopathy with pain for more than 6 weeks
3) Evidence of a spinal cord compression
4) Imaging would significantly alter management
Spine radiographs – only recommended if the patient has a history of recent significant trauma, known osteoporosis/aged 70 years
MRI spine is gold standard investigation
Degenerative disc disease management
Highly variable and patient-dependent
Acute stage – adequate pain relief is the mainstay of treatment
Encouraging mobility within patient limits is recommended for the treatment of acute low back pain, with PT for strengthening exercises
Referral to the pain clinic if pain > 3 months
No evidence to support surgical intervention
