Orthopaedics - Spine

Question 1

Symmptoms of lesion in Dorsal column lesion

Answer 1

Loss vibration and proprioception

Tabes dorsalis, SACD

Question 2

Symmptoms of lesion in Spinothalamic tract lesion

Answer 2

Loss of pain, sensation and temperature

Question 3

Symmptoms of lesion in Central cord lesion

Answer 3

Flaccid paralysis of the upper limbs

Question 4

Infarction spinal cord results in what signs

Answer 4

Dorsal column signs (loss of proprioception and fine discrimination

Question 5

Cord compression results in what signs

Answer 5

UMN signs
Malignancy
Haematoma
Fracture

Question 6

Osteomyelitis is normally progressive

Answer 6

True

Question 7

Osteomyelitis - which parts of the spine are affected with which patient groups?

Answer 7

Staph aureus in IVDU, normally cervical region affected

Thoracic region affected in TB

Question 8

Osteomyelitis - what type of infections in immunocompromised?

Answer 8

Fungal

Question 9

What is Brown-sequard syndrome & what signs do you get?

Answer 9

Hemisection of the spinal cord
Ipsilateral paralysis
Ipsilateral loss of proprioception and fine discrimination
Contralateral loss of pain and temperature

Question 10

Describe the dermatomal distribution of C2 to C4

Answer 10

The C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle. C4 covers the area just below the clavicle.

Question 11

Describe the dermatomal distribution of C5 to T1

Answer 11

Situated in the arms. C5 covers the lateral arm at and above the elbow. C6 covers the forearm and the radial (thumb) side of the hand. C7 is the middle finger, C8 is the medial aspect of the hand, and T1 covers the medial side of the forearm.

Question 12

Describe the dermatomal distribution of T2 to T12

Answer 12

The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is situated at the umbilicus. T12 ends just above the hip girdle.

Question 13

Describe the dermatomal distribution of L1 to L5

Answer 13

The cutaneous dermatome representing the hip girdle and groin area is innervated by L1 spinal cord. L2 and 3 cover the front part of the thighs. L4 and L5 cover medial and lateral aspects of the lower leg.

Question 14

Describe the dermatomal distribution of S1 to S5

Answer 14

S1 covers the heel and the middle back of the leg. S2 covers the back of the thighs. S3 cover the medial side of the buttocks and S4-5 covers the perineal region. S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.

Question 15

Describe myotomes in the upper limb

Answer 15

Elbow flexors/Biceps	C5
Wrist extensors	C6
Elbow extensors/Triceps	C7
Long finger flexors	C8
Small finger abductors	T1

Question 16

Describe myotomes in the lower limb

Answer 16

Hip flexors (psoas)	L1 and L2
Knee extensors (quadriceps)	L3
Ankle dorsiflexors (tibialis anterior)	L4 and L5
Toe extensors (hallucis longus)	L 5
Ankle plantar flexors (gastrocnemius)	S1

Question 17

The anal sphincter is innervated by

Answer 17

S2,3,4

Question 18

What does Froment’s sign assess

Answer 18

ulnar nerve palsy

Adductor pollicis muscle function tested

Question 19

Describe Froment’s sign?

Answer 19

Hold a piece of paper between their thumb and index finger. The object is then pulled away. If ulnar nerve palsy, unable to hold the paper and will flex the flexor pollicis longus to compensate (flexion of thumb at interphalangeal joint).

Question 20

Describe Phalen’s test

Answer 20

Assess carpal tunnel syndrome

Hold wrist in maximum flexion and the test is positive if there is numbness in the median nerve distribution.

Question 21

Describe Tinel’s sign

Answer 21

Assess for carpal tunnel syndrome
Tap the median nerve at the wrist and the test is positive if there is tingling/electric-like sensations over the distribution of the median nerve.

Question 22

Tine;s more sensitive than Phalens

Answer 22

false

Phalens most sensitive

Question 23

Lower back pain (LBP) is one of the most common presentations seen in practice & majority of presentations will be of a non-specific muscular nature

Answer 23

true

Question 24

Red flags for lower back pain

Answer 24

age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever

Question 25

Ankylosing spondylitis typical story

Answer 25

Typically a young man who presents with lower back pain and stiffness Stiffness is usually worse in morning and improves with activity

Question 26

``` In ankylosing spondylitis Peripheral arthritis (?%, more common if female) ```

Answer 26

25%

Question 27

Spinal stenosis acute/ gradual onset

Answer 27

gradual

Question 28

spinal stenosis symptoms

Answer 28

Unilateral or bilateral LEG pain (with or without back pain) Numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as 'aching', 'crawling'. Relieved by sitting down, leaning forwards and crouching down

Question 29

Peripheral arterial disease sx

Answer 29

Pain on walking, relieved by rest | Absent or weak foot pulses and other signs of limb ischaemia

Question 30

Peripheral arterial disease PMH

Answer 30

smoking and other vascular diseases

Question 31

Facet join pain is always acute

Answer 31

May be acute or chronic

Question 32

Facet join pain examination findings

Answer 32

On examination there may be pain over the facets. The pain is typically worse on extension of the back

Question 33

Facet join pain sx

Answer 33

Pain worse in the morning and on standing

Question 34

Spinal stenosis clinical exam often normal

Answer 34

true

Question 35

confirm diagnosis ix spinal stenosis

Answer 35

MRI

Question 36

non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) always doe a lumbar spine x ray

Answer 36

false | lumbar spine x-ray should not be offered

Question 37

non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) when is MRI indicated

Answer 37

should only be offered to patients with non-specific back pain 'only if the result is likely to change management' and to patients where malignancy, infection, fracture, cauda equina or ankylosing spondylitis is suspected it is the most useful imaging modality as no other imaging can see neurological / soft tissue structures

Question 38

non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) - advice

Answer 38

try to encourage self-management | stay physically active and exercise

Question 39

non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) - analgesia

Answer 39

NSAIDS are now recommended first-line for patients with back pain. This follows studies that show paracetamol monotherapy is relatively ineffective for back pain proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given NSAIDs NICE guidelines on neuropathic pain should be followed for patients with sciatica

Question 40

non-specific lower back pain (i.e. not due to malignancy, infection, trauma etc) - other treatments

Answer 40

exercise programme: 'Consider a group exercise programme (biomechanical, aerobic, mindbody or a combination of approaches) within the NHS for people ' manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) 'but only as part of a treatment package including exercise, with or without psychological therapy.' radiofrequency denervation epidural injections of local anaesthetic and steroid for acute and severe sciatica

Question 41

A prolapsed lumbar disc usually produces what type of pain picture

Answer 41

clear dermatomal leg pain associated with neurological deficits leg pain usually worse than back pain often worse when sitting

Question 42

Features of L3 nerve root compression

Answer 42

Sensory loss over anterior THIGH Weak quadriceps Reduced knee reflex Positive femoral stretch test

Question 43

Features of L4 nerve root compression

Answer 43

Sensory loss anterior aspect of KNEE Weak quadriceps Reduced knee reflex Positive femoral stretch test

Question 44

Features of L5 nerve root compression

Answer 44

Sensory loss dorsum of foot Weakness in foot and big toe dorsiflexion Reflexes intact Positive sciatic nerve stretch test

Question 45

Features of S1 nerve root compression

Answer 45

Sensory loss posterolateral aspect of leg and lateral aspect of foot Weakness in plantar flexion of foot Reduced ankle reflex Positive sciatic nerve stretch test

Question 46

mx prolapsed disc

Answer 46

similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises if symptoms persist 9e.g. after 4-6 weeks) then referral for consideration of MRI is appropriate

Question 47

What is lumbar spinal stenosis

Answer 47

Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk prolapse or other similar degenerative changes.

Question 48

lumbar spinal stenosis presentation

Answer 48

combination of back pain, neuropathic pain and symptoms mimicking claudication.

Question 49

lumbar spinal stenosis - how to differentiate from true claudication

Answer 49

One of the main features that may help to differentiate it from true claudication in the history is the positional element to the pain. Sitting is better than standing and patients may find it easier to walk uphill rather than downhill. The neurogenic claudication type history makes lumbar spinal stenosis a likely underlying diagnosis, the absence of such symptoms makes it far less likely.

Question 50

Pathology of lumbar spinal stenosis

Answer 50

Degenerative disease is the commonest underlying cause. Degeneration is believed to begin in the intervertebral disk where biochemical changes such as cell death and loss of proteoglycan and water content lead to progressive disk bulging and collapse. This process leads to an increased stress transfer to the posterior facet joints, which accelerates cartilaginous degeneration, hypertrophy, and osteophyte formation; this is associated with thickening and distortion of the ligamentum flavum. The combination of the ventral disk bulging, osteophyte formation at the dorsal facet, and ligamentum flavum hyptertrophy combine to circumferentially narrow the spinal canal and the space available for the neural elements. The compression of the nerve roots of the cauda equina leads to the characteristic clinical signs and symptoms of lumbar spinal stenosis.

Question 51

Diagnosis of lumbar spinal stenosis

Answer 51

MRI scanning is the best modality for demonstrating the canal narrowing.

Question 52

Treatment of lumbar spinal stenosis

Answer 52

Laminectomy

Question 53

What is cauda equina syndrome

Answer 53

rare but serious condition in which the lumbosacral nerve roots that extend below the spinal cord are compressed.

Question 54

It is important to consider CES in any patient who presents with new/worsening lower back pain.

Answer 54

true

Question 55

CES Late diagnosis may lead to

Answer 55

permanent nerve damage resulting in long term leg weakness and urinary/bowel incontinence.

Question 56

Causes CES

Answer 56

``` the most common cause is a central disc prolapse this typically occurs at L4/5 or L5/S1 other causes include: tumours: primary or metastatic infection: abscess, discitis trauma haematoma ```

Question 57

It is important to recognise that CES may present in a variety of ways and there is no one symptom/sign that can diagnose nor exclude CES

Answer 57

true

Question 58

Ix & Mx CES

Answer 58

urgent MRI | Surgical decompression

Question 59

Possible features CES

Answer 59

``` low back pain bilateral sciatica reduced sensation/pins-and-needles in the perianal area decreased anal tone urinary dysfunction ```

Question 60

bilateral sciatica is present in ?% of CES

Answer 60

50%

Question 61

decreased anal toneis highly specific for CES

Answer 61

it is good practice to check anal tone in patients with new-onset back pain however, studies show this has poor sensitivity and specificity for CES

Question 62

Describe urinary dysfunction in CES

Answer 62

e.g. incontinence, reduced awareness of bladder filling, loss of urge to void incontinence is a late sign that may indicate irreversible damage

Question 63

Cervical spondylosis is an extremely common condition that results from

Answer 63

osteoarthritis.

Question 64

Cervical spondylosis presentation

Answer 64

It most commonly presents as neck pain although referred pain may mimic headaches etc.

Question 65

Cervical spondylosis complications

Answer 65

radiculopathy and myelopathy.

Question 66

what is osteoporosis

Answer 66

condition where bones gradually decrease in bone mineral density, thus increasing the likelihood of fragility fractures. Fragility fractures are fractures that occur as a result of mechanical forces which would not usually lead to a fracture

Question 67

one of the most common sites of osteoporotic fractures is

Answer 67

vertebra

Question 68

Osteoporotic vertebral fracture presentation

Answer 68

Asymptomatic: an osteoporotic vertebral fracture may be diagnosed through an incidental finding on X-ray Acute back pain Breathing difficulties: Gastrointestinal problems

Question 69

Osteoporotic vertebral fracture - why do you get breathing difficulties & gi ISSUES

Answer 69

changes in the shape and length of vertebrae lead to the compression of organs such as the lungs, heart and intestine Gastrointestinal problems: due to compression of abdominal organs

Question 70

Osteoporotic vertebral fracture are mostly caused by trauma

Answer 70

false | Only a minority of patients will have a history of fall/trauma

Question 71

Osteoporotic vertebral fracture signs

Answer 71

Loss of height: vertebral osteoporotic fractures of lead to compression of the spinal vertebrae hence a reduction in overall length of the spine and thus the patient becomes shorter Kyphosis (curvature of the spine) Localised tenderness on palpation of spinous processes at the fracture site

Question 72

Osteoporotic vertebral fracture first ix ( what does this show)

Answer 72

X-ray of the spine: This should be the first investigation ordered and may show wedging of the vertebra due to compression of the bone. An X-ray of the spine may also show old fractures (which can have a sclerotic appearance)

Question 73

Osteoporotic vertebral fracture other ix

Answer 73

CT spine: gives a more detailed view of the bone structure, therefore can visualise the extent/features of the fracture more clearly MRI spine: Useful for differentiating osteoporotic fractures from those caused by another pathology e.g. a tumour

Question 74

Osteoporotic vertebral fracture - assessing risk of second event

Answer 74

risk factors are taken into account and a dual-energy X-ray absorptiometry (DEXA) scan should be considered. DEXA scans essentially assess bone mineral density. According to NICE, the FRAX tool or QFracture tool can be used to estimate the 10-year risk of a fracture. These tools each require the clinician to input patient information into a form and this information is used by the programme to calculate the risk.

Question 75

Osteoporosis is far more common in females than in males.

Answer 75

true The male-to-female ratio is 1:6. 25% of women will have developed osteoporosis by the age of 80 .

Question 76

Risk factors for osteoporotic fractures

Answer 76

Advancing age is a major risk factor osteoporotic fractures: Previous history of a fragility fracture Frequent or prolonged use of glucocorticoids History of falls Family history of hip fracture ``` Low BMI (< 18.5) Tobacco smoking High alcohol intake: > 14 units/week for women, > 21 units/week for men ```

Question 77

When should people be consider for fracture assessment?

Answer 77

Women ≥ 65 years old and men ≥ 75 years old should be considered for fracture risk assessment.

Question 78

reduced oestrogen levels is a risk factor for osteoporosis.

Answer 78

true

Question 79

causes of secondary osteoporosis

Answer 79

Cushing’s disease, hyperthyroidism, chronic renal disease

Question 80

High BMI is risk factor for osteoporosis

Answer 80

false | low <18.5