Spine Flashcards
23 year-old male with neck and back stiffness.
Ankylosing spondylitis
Background
- Inflammation of sacroiliac joints and axial skeleton
- HLA-B27 positive
Clinical features
- Insidious low back pain and stiffness
- Worse in morning, better with exercise
- Extraskeletal symptoms
- Anterior uveitis, CV disease, cauda equina syndrome, IgA nephropathy and amyloidosis
Imaging
- “Bamboo spine” = fusion of vertebral body
Treatment
- NSAIDs, DMARDs, anti-TNF, exercise
- Surgery
45 yo male who woke up with sudden inability to move his legs.
Anterior spinal artery (ASA) infarct
Background
- Causes anterior cord syndrome
- Etiologies:
- Atherosclersois, dissecting aneurysm, cholesterol embolism, rupture of spinal AVM, vasculitides (SLE, PAN)
Clinical presentation
- Acute motor paralysis (bilateral)
- Loss of pain/temperature (bilateral)
- Sparing of propioception/vibratory
- Autonomic dysfunction
- Orthostatic hypotension, sexual dysfunction, bowel/bladder dysfunction
Imaging
- Hyperintensities + restricted diffusion on DWI in anterior 2/3 of spinal cord
- “Snake eyes” of corticospinal tracts
Treatment
- Rehab
34 year-old man with bilateral LE weakness and areflexia.
Anterior horn cellitis
- “Owl’s eye” = hyperintensity of central gray matter
56 year-old man with severe burning and tingling in all four extremities.
B12 myelopathy
Background
- B12 deficiency causes neuro dysfunction in peripheral and optic nerves, posterior and lateral columns
Clinical presentation
- Cold, numbness, tingling in tips of toes and fingertips
- Limb weakness and ataxia in untreated patients
- Loss of vibratory and positional sensation → loss of light touch, pain, temperature
- Romberg (+), Babinski (+)
- Hyperreflexia of knee, absent reflex at ankle
Imaging
- Hyperintensities in posterior columns
- Spinal cord atrophy in chronic B12 deficiency
Treatment
- Parenteral or oral cobalamin
56 year-old man with severe burning and tingling in extremities.
HIV-associated vacuolar myelopathy (VM)
Background
- Late stage HIV, low CD4
- Vacuolization of lateral and posterior columns
- Looks like B12 myelopathy
Clinical features
- Gradual painless leg weakness and stiffness
- Hypperreflexia, Babinski (+)
- Sensory ataxia
- Bladder, bowel incontinence
Imaging
- Symmetric, non-enhancing hyperintensities present on multiple contiguous slices
- May be confined to posterior columns (gracile tracts) or may be diffuse
Treatment
-
Supportive care, rehabilitation
- HAART doesn’t help
56 year-old man with progressive myelopathy.
Spinal AVM
Background
- Abnormal collection of blood vessels in spinal canal
- AVMs may be dural (most common), intradural, or intramedullary
- Congenital
Clinical features
- Progressive back pain, sensory loss, weakness over months/years
- Hyperreflexia, hyertonic, paraparesis, sensory loss caudal to lesion
- Hemorrhage - acute and severe back pain, weakness or paralysis, numbness, incontinence
- Bruits over spinal cord
Imaging
- MRA or CTA
- Digital subtration angiography (DSA) = gold standard
Treatment
- Surgical ligation or resection
- Endovasvular embolization
- Spinal radiation
25 y/o M with sudden paraparesis.
Spinal cavernoma
Background
- Sinusoidal vascular channels
Clinical presentation
- Progressive myelopathy due to microhemorrhages or mass effect
- Acute hemorrhage = severe back pain, weakness or paralysis, numbness, UMN signs
Imaging
- “Popcorn” look = blood products of different ages
- No signal on angiogram due to low flow
Treatment
- Surgery only if symptomatic
56 y/o M with myelopathy and back pain.
Epidural metastases
Background
- Breast, lung, prostate metastases are epidural
- Compression at thoracic level
Clinical features
- Progressive pain
-
Myelopathy
- Paraparesis, loss of sensation, hyperreflexia, Babinski +, loss of sphincter tone
Imaging
- Multiple lesions
Treatment
- High dose IV steroids
- Radiation
- Decompressive surgery may be necessary
45 y/o M with radicular pain and myelopathy.
Schwannoma
Background
- A nerve sheath tumor
- Intradural, extramedullary
- Associated with NF1 or NF2
Clinical features
- Radicular pain worse at night and in the morning that resolves during the day
-
Myelopathy
- Paraparesis, sensory loss, hyperreflexia, Babinski+, loss of sphincter tone
Imaging
- Enhancement on T1WI
Treatment
- Surgery
- No radiation or chemo!
56 y/o female with hand numbness and exam supports evidence of myelopathy.
Syringomyelia
Background
- Fluid-filled cavity in spinal cord
- Etiology - Chiari malformation, trauma, idiopathic
Clinical features
-
Central cord syndrome = “cape-like”
- Pain and temperature loss
- Proprioeption and vibration in tact
- Muscle weakness
Imaging
- Dilated cavity with same intensity as CSF
66 y/o F and 78 y/o M each with myelopathy.
Cervical spondylotic myelopathy (CSM)
Background
- Degenerative changes of the spine
- Most common spinal disorder in elderly
Clinical features
- Progressive neck pain radiating to arms, neck stiffness
- Weakness and atrophy of arms (LMN)
- Weakness and spasticity of legs (UMN)
- Asymmetric sensory deficits
- Lhermitte’s sign
Treatment
- Collar or neck brace, physical therapy
- Decompression surgery
28 y/o male from South America with seizures and subacute onset of leg weakness.
Neurocystercercosis of the spine
55 y/o female with symptoms and signs suggestive of myelopathy.
Spinal lipoma
Indian male with pain and weakness.
Pott’s disease
23 y/o male involved in a Motorcycle Accident.
Cord contusion
56 y/o M with a very slowly progressive myelopathy.
Spinal meningioma
- Extradural, intramedullary
25 y/o M with arm pain, triceps weakness.
Herniated disc
65 y/o M with sudden onset pain and myelopathy.
Spinal epidural hematoma
IV drug user with back pain and weakness.
Spinal epidural abscess
70 y/o with progressive leg weakness.
Synovial cyst
76 years old female with severe back pain and incontinence.
Burst fracture
