Diseases of the Spinal Cord and Nerve Roots Flashcards
(142 cards)
1
Q
Presentation of UMN signs
A
No wasting
Increased tone
Increased reflexes
Pyramidal pattern of weakness
2
Q
What is the pyramidal pattern of weakness in UMN lesion?
A
Flexors stronger than extensors
3
Q
What does UMN stand for?
A
Upper motor neurone
4
Q
What does LMN stand for?
A
Lower motor neurone
5
Q
Presentation of LMN signs
A
Decreased tone Decreased reflexes Plantar flexor Weakness Muscle wasting
6
Q
What does a hemicord sensory lesion lead to?
A
Brown-sequard syndrome
7
Q
What does a radiculopathy lead to?
A
Dermatomal sensory loss
8
Q
What are the types of sensory signs?
A
Myelopathy
Hemicord lesion
Radiculopathy
9
Q
If there was a C5 cord lesion, what possible signs may be present?
A
Wasting of C5 innervated muscles Increased tone in LL > UL Reflexes - decreased in biceps - increased all lower reflexes Sensory level
10
Q
Extrinsic causes of myelopathy / radiculopathy
A
Tumour Hemorrhage AVM, dural fistula Degenerative (spine) Trauma
11
Q
Causes of myelopathy
A
Inflammation - Demyelination (MS) - autoimmune (antibody mediated e.g. aquaporin 4, lupus) - sarcoid Vascular - ischaemic vs haemorrhage Infective - viral (HSV/HZV, - bacterial (TB, lyme, syphillis, brucella) - schistosomiasis Metabolic - B12 deficiency Malignant / infiltrative Congenital / genetic - friedrichs ataxia, spinocerebellar ataxias Idiopathic
12
Q
What is ischaemic myelopathy?
A
Spinal stroke/infarction
13
Q
What foodstuffs is abundant in B12?
A
Meat
Fish
Animal by products
Legumes
14
Q
Absorption of B12 from the gut requires what? Where is this produced from?
A
Intrinsic factor (a binding protein) Produced by gastric parietal cells
15
Q
What is pernicious anaemia?
A
Autoimmune condition in which antibodies to intrinsic factor prevent vit B12 absorption
16
Q
What is vit B12 deficiency a complication of?
A
Total gastrectomy
Crohn’s
Tape worms
17
Q
What of the nervous system does Vit B12 affect?
A
Myelopathy (L'hermittes) Peripheral neuropathy Brain Eye/optic nerves Brainstem Cerebellum
18
Q
Presentation of B12 deficient myelopathy
A
Paraesthesia hands and feet, areflexia First UMN sign extensor plantars Degeneration of corticospinal tracts - paraplegia Degeneration of dorsal colums = sensory ataxia Painless retention of urine
19
Q
Investigations of B12 deficient myelopathy
A
FBC
Blood film
B12
20
Q
Treatment of B12 deficient myelopathy
A
Intramuscular B12 injection
21
Q
Causes of spinal cord ischaemia
A
Atheromatous disease (aortic aneurysm) Thromboembolic disease (endocarditis, AF) Arterial dissection (aortic) Systemic hypotension Thrombotic haematological disease Hyper viscosity syndromes Vasculitis Venous occlusion Endovascular procedures Decompression sickness Meningovascular syphillis
22
Q
Presentation spinal cord stroke
A
Ischaemic pain
- back / radicular
- visceral referred pain
- radiates around where intercostal nerves would be
Weakness
- usually paraperesis rather than quadraparesis
Numbness and paraesthesia
Urinary syndromes
- retention
- followed by bladder and bowel incontinence as spinal shock settles
Acute stages of UMN in spinal shock - floppiness
23
Q
What risk factors may someone who presents with a spinal cord stroke have?
A
Vascular risk factors
24
Q
What artery is usually affected in spinal cord stroke?
A
Anterior spinal artery
25
Occlusion of what artery can present as partial brown sequard syndrome?
Occlusion of central sulcal artery
26
Investigations of spinal cord stroke
MRI
27
Treatment of spinal cord stroke
OT and physio
Manageme vascular risk factors
Reduce risk of recurrence
28
How to reduce the risk of recurrence of spinal stroke?
Maintain adequate BP
Reverse hypovolaemia/arrythmia
Antiplatelet therapy
29
What does the return of function depend on in spinal cord stroke?
The degree of parenchymal damage
30
What is a good prognostic indicator of recovery in spinal cord stroke?
Significant motor recovery within 24 hours
31
Mortality of spinal cord stroke
20%
32
What is demyelinating myeltiis a common cause of?
Medical spinal cord disease
33
What is MS characterised by?
Pathological lesions of inflammation and demyelination leading to temporary neuronal dysfunction
34
What does MS affect?
White matter of the CNS
35
Treatment of MS
Supportive
| Methylprednisolone
36
What are the vertebral ligaments?
```
Anterior longitudinal
Posterior longitudinal
Ligamentum flavum
Interspinal ligament
Supraspinous ligament
```
37
Where does the spinal cord extend from and to?
C1 - L2
38
What dermatome is C6?
Thumb
39
What dermatome is C7?
Middle finger
40
What dermatome is C8?
Pinky
41
C5 myotome
Elbow flexors
42
C6 myotome
Wrist extensor
43
C7 myotome
Elbow extensors
44
C8 myotome
Finger extensors
45
T1 myotome
Intrinsic hand muscles
46
L2 myotome
Hip flexors
47
L3 myotome
Knee extensors
48
L4 myotome
Ankle dorsiflexors
49
L5 myotome
Long toe extensors
50
S1 myotome
Ankle plantar flexors
51
Signs of UMN lesion
```
Weakness PRESENT
Atrophy ABSENT
Reflexes INCREASED
Tone INCREASED
Fasiculations ABSENT
Babinski PRESENT
```
52
Signs of LMN Lesions
```
Weakness PRESENT
Atrophy PRESENT
Reflexes DECREASED
Tone DECREASED
Fasiculations PRESENT
Babinski ABSENT
```
53
What is classed as an UMN and LMN lesion?
UMN - anterior horn of the spinal cord or above
| LMN - distal to this
54
What would a C6 spinal cord lesion present with?
Weakness in elbow below sensory level at C6 and in legs
Reduced sensations after C6 - starts to have weakness in their hands
Power in shoulders but probably not below that
Increased tone in legs
Brisk reflexes
Babinski +ve
UMN!!
55
Definition of myelopathy. Is it an UMN or LMN lesion?
Neurological deficit due to compression of the spinal cord
| UMN
56
What would a L4 nerve root lesion present with?
```
Pain down ipsilateral leg
Numbness in T4 dermatome
Weakness in ankle dorsiflexion = myotomes 2,3,4
Reduced knee jerk
LMN!!
```
57
Definition of radiculopathy. Is it an UMN or LMN lesion?
Compression of the nerve root leading to dermatomal and myotomal deficits
LMN
58
Definition of disc prolapse
Acute herniation of intervertebral disc causing compression of spinal roots or spinal cord
59
Presentation of disc prolapse
Acute onset pain
- leg / arm
Sciatica
Numbness and weakness in the distribution of the nerve root involved
60
Investigation of disc prolapse
MRI
61
Definition of sciatica
Shooting pain down the leg into the ankle
62
What will a disc prolapse in the cervical spine cause?
Myelopathy (UMN lesion)
63
What will a disc prolapse in the lumbar region cause?
UMN of L1 and LMN below it
64
Treatment of disc prolapse
Rehab
Nerve root injection
- steriods and anaesthetics
Lumbar/cervical disectomy
65
What is a discectomy?
Remove the disc
66
Nerve root injections give pain relief for approx. how long?
2 weeks
67
Types of spinal tumours
Extradural (55%)
Intradural (40%)
Intramedullary (5%)
68
Types of intramedullary spinal tumours
Astrocytome
Ependymoma
Teratoma
Hemangioblastoma
69
Types of intradural spinal tumours
Meningioma
Neurofibroma
Lipoma
70
Types of extradural spinal tumours
```
Mets
- lung
- breast
- prostate
Primary bone tumours
- chondromas
- oesteoblastomas
- osteiud osteoma
```
71
Presentation of malignant cord compression
Pain
Weakness
Sphincter disturbance
72
Treatment of malignant cord compression
Surgical decompression
Radiotherapy
Cancer treatment
73
Examples of spinal infections
Osteomyelitis
Discitis
Epidural abscess
74
Where would you get osteomyeltiis of the spine?
Within the vertebral body
75
Where would you get discitis of the spine?
Intervertebral disc
76
Where would you get an epidural abscess?
Epidural space
77
Presentation of epidural abscess
Back pain
Pyrexia
Focal neurology
78
Investigations of epidural abscess
Urgent MRI
79
Treatment of epidural abscess
Urgent surgical decompression
| Long term IV antibiotics
80
Causative organisms of epidural abscess
Staph aureus
Streptococcus
E coli
81
Risk factors for epidural abscess
IV drug abuse
DM
Chronic renal failure
Alcoholism
82
Risk factors for osteomyelitis of the spine
```
IV drug abuse
DM
Chronic renal failure
Alcoholism
AIDs
```
83
Treatment of osteomyleitis of the spine
Antibiotics
| Surgery if evidence of neurology
84
Who is the loss of normal spinal structure seen in?
Older patients
85
Pathology of normal loss of spinal structure in elderly
```
Product of
- disc prolapse
- ligamentum hypertrophy
- oestophyte formation
Leading to
- myelopathy
- radiculopathy
```
86
Definition of cervical spondylosis
Umbrella term for degenerative change in cervical spine leading to spine and nerve root compression
87
Presentation of cervical spondylosis
Myelopathy
| Radiculopathy
88
Speed of onset of cervical spondylosis
Months to years
89
Treatment of cervical spondylosis
Conservative if no / mild myelopathy
| Surgery for progressive / severe
90
Presentation of lumbar spinal stenosis
Pain down both legs 'spinal claudication'
| Worse on walking/standing and relieved by sitting/bending forward
91
Treatment of lumbar spinal stenosis
Lumbar laminectomy
92
Is lumbar spinal stenosis an emergency?
No
93
What is similar to lumbar spinal stenosis that is an emergency?
Cauda equina syndrome
94
What is cauda equina syndrome?
Large disc prolapse in combination with clinical signs
| All nerve roots are compressed
95
What is the triad of cauda equina syndrome?
Bilateral sciatica
Saddle anaesthesia
Urinary dysfunction
96
Investigations of cauda equina syndrome
Urgent MRI
97
Treatment of cauda equina syndrome
Emergency lumbar dissectomy
98
What does brown sequard syndrome result in?
LOSS of proprioception and PARALYSIS on the SAME side as the lesion
LOSS of pain and temp on the OPPOSITE SIDE of the lesion
99
What signs does MND result in? What does it affect?
A combination of UMN and LMN signs
| Affects both upper (corticospinal) tracts and lower tracts
100
What signs does poliomyelitis result in? What does it affect?
Affects ANTERIOR HORN CELLS resulting in LMN signs
101
What tracts does brown sequard syndrome affect?
1. Lateral corticospinal tracts
2. Dorsal columns
3. Lateral spinothalamic tracts
102
What causes subacute combined degeneration of the spinal cord?
Vitamin B12 and E deficiency
103
What tracts does the subacute combined degeneration of the spinal cord affect?
1. Lateral corticospinal tracts
2. Dorsal columns
3. Spinocellebellar tracts
104
What does subacute combined degeneration of the spine result in?
Bilateral spastic paralysis
Bilateral loss of proprioception and vibration sensation
Bilateral limb ataxia
105
What does friedrichs ataxia result in?
1. Lateral corticospinal tracts
2. Dorsal columns
3. Spinocerebellar tracts
106
Presentation of friedrichs ataxia
Bilateral spastic paralysis
Bilateral loss of proprioception and vibration sensation
Bilateral limb ataxia
Cerebellar ataxia e.g. intention tremor
107
What tracts are affected in anterior spinal artery occlusion?
Lateral corticospinal tracts
| Lateral spinothalamic tracts
108
Presentation of anterior spinal artery occlusion
Bilateral spastic paresis
| Bilateral loss of pain and temp sensation
109
Tracts affected in synringomyelia
Ventral horns
| Lateral spinothalamic tract
110
Presentation of synringomyelia
```
Flaccid paralysis (typically affecting intrinsic hand muscles)
Loss of pain and temp sensation
```
111
What tracts are affected in MS?
Asymmetrical, varying spinal tracts involved
112
What tract is involved in neurosyphilis?
Dorsal columns
113
Presentation of neurosyphillis
Loss of proprioception and vibration sense
114
Risk factors for degenerative cervical myelopathy
Smoking (due to effects on intervertebral discs)
Genetics
Occupation (high axial loading)
115
Symptoms of degenerative cervical myelopathy
```
VERY VARIABLE
Pain (neck, upper and lower limbs)
Loss of motor function
Loss of sensory function - numbness
Loss of autonomic function (incontinence, impotence)
Symptoms of carpal tunnel syndrome
Hoffmans sign
```
116
What does hoffmans sign investigate for and explain it?
Degenerative cervical myelopathy
Gently flick one finger on a patients hand - +ve test is when twitching of the other fingers on the same hand in response to the flick
117
Investigation of degenerative cervical myelopathy
MRI spine - gold standard
118
Management of degenerative cervical myelopathy
Urgent referral to assessment by special spinal services
| Decompressive surgery
119
What in degenerative cervical myelopathy confers best prognosis?
Early surgery within 6 months of diagnosis
120
If neuropathic pain originally doesn't resolve with conventional treatment, what opoid can be tried?
Tramadol
121
What is the only nerve root that originates below a vertebrae? How does this differ from other nerve root names?
C8
| The rest of the cervical spine roots derive their name from the vertebrae below them
122
Nerve root of ankle reflex
S1 - S2
123
Nerve root of knee reflex
L3 - L4
124
Nerve root of biceps reflex
C5 - C6
125
Nerve root of triceps reflex
C7 - C8
126
What does a high stepping gait compensate for?
Foot drop
127
What is bilateral foot drop meant to be due to?
Peripheral neuropathy
128
What is unilateral foot drop due to?
Common peroneal nerve lesion
129
What does the lesion of the common peroneal nerve lead to?
Weakness of dorsiflexion
| Weakness of foot eversion
130
What indicates autonomic dysreflexia and when does this occur?
```
Occurs if the spinal cord injury is above the C6 level
Combination of
- severe HTN
- flushing
- sweating
- no congruent response in HR
```
131
Triggers of autonomic dysreflexia
Things that cause a sympathetic spinal reflex via thoracolumbar outflow e.g.
- faecal impaction
- urinary retention
Others
132
Management of autonomic dysreflexia
Removal / control of stimulus
| Tx life threatening HTN or bradycardia
133
What is subacute degeneration of the spinal cord often due to?
Vitamin B12 deficiency
134
What could be a warning sign for degenerative cervical myelopathy?
Progressive condition, worsening, deteroriation or new symptoms
135
What is thoracic outlet syndrome?
A disorder involving compression of the brachial plexus, subclavian artery or vein at the site of the thoracic outlet
136
Types of thoracic outlet syndrome
Can be
- neurogenic OR
- vascular
137
Pathology of TOS (thoracic outlet syndrome)
When neck trauma occurs in individuals with anatomical predispositions - either an acute incidence or repeated stress
Anatomical anomalies can be either
- soft tissue (70%) or
- osseous structures (30%)
138
Example of a well known osseous structure predisposing to TOS
Presence of a cervical rib
139
Examples of soft tissue anomalies predisposing to TOS
Scalene muscle hypertrophy
| Anomalous bands
140
What is there usually a history of preceding TOS?
Neck trauma
141
Presentation of neurogenic TOS
Painless muscle wasting of the hands with patients complaining of hand weakness e.g. grasping
Sensory symptoms such as numbness and tingling
If autonomic nerves are involved
- cold hands
- blanching
- swelling
142
Presentation of vascular TOS
Subclavian vein compression leads to painful diffuse arm swelling with distended veins
Subclavian artery compression leads to painful arm claudication and in severe cases ulceration and gangrene
