Spinal symposium

Question 1

What is the difference between Complete and incomplete SC injury

Answer 1

Complete – no motor or sensory function distal to lesion, no anal squeeze, no sacral sensation, ASIA grade A, no chance of recovery. Incomplete – some function is present below site of injury, more favourable prognosis overall.

Question 2

What is tetraplegia

Answer 2

Aka quadriplegia. Partial or total loss of all four limbs and trunk loss of motor/sensory function in cervical segments of SC

Question 3

What is paraplegia

Answer 3

Partial or total loss of use of LL. Impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of SC. Arm function spared. Possible impairement of function of trunk.

Question 4

Describe central cord syndrome

Answer 4

Injury to central parts of the cord, can affect corticospinal and spinothalamic tracts. Seen in older patients (arthritic neck). Is a hyperextension injury. Centrally cervical tracts more involved. Usually weakness of arms >legs. Perianal sensation + lower extremity power preserved.

Question 5

Describe anterior cord syndrome

Answer 5

Poor prognosis, whole area supplied by anterior spinal artery affected, (still have dorsal column). Hyperflexion injury. Anterior compression fracture, damaged anterior spinal artery. Fine touch, proprioception + vibration preserved. Profound weakness.

Question 6

Describe Brown-Sequard syndrome

Answer 6

Hemi-section of the cord. From penetrating injuries (e.g. stabbing/gunshot). 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).

Question 7

What is the key to management of SC injuries

Answer 7

Key of management is to prevent secondary insult. Particularly in patients with incomplete injury (no hope for complete). Need to immobilise and maintain physiological processes (e.g. oxygenate). ABCD (Cervical spine control with immobilising collar, ventilate/oxygenate, fluids). ATLS. X ray, MRI.

Question 8

Describe the difference between spinal shock and neurogenic shock

Answer 8

Spinal shock – transient depression of cord function below level of injury (response to any SC injury), flaccid paralysis, arreflexia, last several hours to day after injury. Neurogenic shock – hypotension, bradycardia, hypothermia, injuries above T6, is secondary to disruption of sympathetic outflow (tract)

Question 9

Describe the degeneration of intervertebral disc by normal ageing

Answer 9

• Decreased water content of discs
• Disc space narrowing
• Degenerative changes on X-ray
• Degenerative changes in facet joints
• Aggravated by smoking etc.

Question 10

Describe the degeneration of intervertebral disc by pathological means

Answer 10

• Tearing of annulus fibrosis and protrusion of the nucleus
• Nerve root compression by osteophytes
• Central spinal stenosis
• Abnormal movement
  o Spondylolysis (defect/stress fracture in arch)
  o Spondylolisthesis

Question 11

What are common causes of lower back pain

Answer 11

• Lumbar disc prolapse
• Spinal stenosis
• Sciatica
• Muscle or ligament injury

Question 12

What are red flag symptoms of low back pain

Answer 12

• Onset age < 20yrs or >55yrs
• Thoracic pain
• Loss of control of bowel or bladder
• Acute onset in elderly
• Nocturnal pain
• Fever, night sweats, weight loss
• History of malignancy
• Abdominal mass
• Weakness or numbness in leg or arm
• Bilateral or alternating leg pain

Question 13

Describe lumbar disc prolapse

Answer 13

Usually L4/5 (followed by L5/S1 then least common L3/4). Most are posterolateral (PLL weakest). Central disc prolapse may give pain in both legs, or may be back pain only. Prolapse presses on emerging nerve coming from cauda equina.

Question 14

What is the usual cause of cauda equina syndrome?

Answer 14

Usually central lumbar disc prolapse. Can also be tumours, trauma, infection (epidural abscess) or iatrogenic.

Question 15

Describe the clinical presentation of cauda equina syndrome

Answer 15

• Injury or precipitating event.
• Location of the symptoms (bilateral buttock + leg pain + varying dysesthesiae +/- weakness beware)
• Bowel or bladder dysfunction (urinary retention +/- incontinence overflow)
• PR exam – saddle anaesthesia (perianal loss of sensation), loss of anal tone & anal reflex
• High index of suspicion in spinal post-op patients with increasing leg pain in presence of urinary retention

Question 16

How would you investigate and treat cauda equina syndrome?

Answer 16

Surgical emergency – following admission, urgent MRI scan, emergency operation within 48 hours, delay results in permanent dysfunction.
Radiography – MRI, If C-I (metal implants, pacemaker, valve replacement) the lumbar CT myelogram
Operative – within 48 hours =, statistically sig improvement and difference is surgery < 48 hours.

Question 17

What is cervical and lumbar spondylosis?

Answer 17

OA. Common. Degenerative change at facet joints, discs, ligaments etc. If severe, can compress whole cord (not just nerve roots) causing myelopathy – UMN signs in limbs (increased tone, brisk reflexes, etc.)

Question 18

What is the usual treatment for spinal stenosis?

Answer 18

Lateral recess, central and foraminal.

• Non operative
• Nerve root injection (apart from central)
• Epidural steroid injection
• Surgery

Question 19

Describe spondylolisthesis

Answer 19

One vertebrae translated on another. Symptoms often vary with type of spondylolisthesis. Treatment depends on symptoms, conservative with life changes, surgery for persistent pain +/- nerve root entrapment