Spinal Cord

Question 1

What are the cervical myotomes?

Answer 1

C5 - shoulder abduction and adduction, elbow flexion
C6 - elbow flexion and wrist extension
C7 - elbow extension, wrist flexion
C8 - wrist flexion, finger flexion
T1 - finger abduction

Question 2

What myotomes are the biceps and brachioradialis reflexes?

Answer 2

C5 and C6

Question 3

What myotome is the triceps reflex?

Answer 3

C7

Question 4

What are the lumbosacral myotomes?

Answer 4

L2 - hip flexion and adduction
L3 - hyp adduction and knee extension
L4 - knee extension, foot inversion and dorsiflexion
L5 - hip extension and abduction, knee flexion, great toe dorsiflexion
S1 - knee flexion, foot plantarflexion and eversion

Question 5

What are the myotomes for the lower limb reflexes?

Answer 5

Knee - L3/4

Great toe - L5

Ankle - S1

Question 6

What is the common cause of spinal cord disease in 16-30 yo.?

Answer 6

Likely trauma of C4/5 or C5/6

Question 7

What is the common cause of spinal cord disease in 30-50 yo.?

Answer 7

Likely disc disease of C5/6 or L4/5 or L5/S1

Question 8

What is the common cause of spinal cord disease in 40+ yo.?

Answer 8

Likely malignancy

Question 9

What are the potential causes of spinal cord problems?

Answer 9

Trauma
Iatrogenic
Osteoporosis
Corticosteroid use
Osteomalacia
Osteomyelitis
Tumour infiltration
Disc herniation
Infection

Question 10

How do spinal cord problems present?

Answer 10

Back pain
Numbness and paraesthesia
Weakness and paralysis
Bladder and bowel dysfunction
Hyper-reflexia
Spinal shock
Neurogenic shoc

Question 11

What happens in spinal shock?

Answer 11

Loss of reflexes, tone and motor function

Question 12

What happens in neurogenic shock?

Answer 12

Following cervical or high thoracic injury

Bradycardia, hypotension, warm dry extremities, peripheral vasodilation, venous pooling, priapism, low cardiac output

Question 13

When should a CT C Spine <1hr be considered?

Answer 13

GCS < 13
Intubated
>65yo
High impact injury
Focal neurological deficit
Paraesthesia of UL or LL

Question 14

How is Spinal cord compression managed?

Answer 14

Immobilise C spine - collar and backboard
Intubate if above C5
Decompressive surgery
Supportive management - VTE prophylaxis, maintain vitals, nutrition, catheter, laxatives, pressure sore prevention

If malignancy - palliative

Abscess - IV Vancomycin, metronidazole and cefotaxime + surgery

Question 15

How should patients with spinal cord disease be assessed?

Answer 15

History - injury method, symptoms (sensory, motor, autonomic, systemic), PMH, IV drugs? osteoporosis?

Imaging - AP and lateral views, CT and plain films, MRI if tumour or abscess suspected

Question 16

How would a complete cord transection present?

Answer 16

Complete loss of all modalities below lesion
Spinal shock
Neurogenic shock - higher cervical
Horners syndrome - higher transection as sympathetics involved
Bowel and bladder involvement if lower transection

Question 17

What can cause brown-sequard?

Answer 17

Trauma
Tumour
Herniation
MS

Question 18

How would brown-sequard present?

Answer 18

Ipsilateral spastic paralysis
Ipsilateral loss of vibration and proprioception
Contralateral loss of pain and temperature

Question 19

What can cause an anterior cord injury?

Answer 19

Flexion injury

Anterior spinal artery damage

Question 20

How would an anterior spinal cord injury present?

Answer 20

Bilateral loss of motor function

Bilateral loss of pain and temperature

Question 21

What can cause posterior cord injury?

Answer 21

Posterior spinal artery damage
Spinal stenosis
B12 deficiency

Question 22

How would posterior cord injury present?

Answer 22

Bilateral loss of vibration and proprioception

Question 23

What causes central cord injury?

Answer 23

Hyperextension injury
Spondylosis
Syringomyelia

Question 24

How would central cord injury present?

Answer 24

Cape like distribution
Pain and temperature affected first
Motor affected more than sensory

Question 25

What would cause cauda equina and how does it present?

Answer 25

Herniated lumbar disc or spinal canal stenosis Saddle anaesthesia Bladder retention - may be overflow incontinence Leg weakness

Question 26

What is cervical spondylosis?

Answer 26

Degeneration of annulus fibrosus + osteophyte formation leads to narrowing of the spinal canal and intervertebral foramina which can lead to a radiculopathy or myelopathy

Question 27

How is the cord irritated in cervical spondylosis?

Answer 27

Osteophytes anteriorly | Thickened ligamentum flavum posteriorly

Question 28

How does cervical spondylosis present?

Answer 28

``` Neck pain and stiffness Referred pain - headache and occipital Lhermitte's sign Cervical muscle spasm Limited range of movement ```

Question 29

What is the difference between radiculopathy and myelopathy?

Answer 29

Radiculopathy - root compression - pain and electrical sensations, numbness, dull reflexes, weakness, wasting of muscles Myelopathy - cord compression - Progressive symptoms, clumsy hands, gait disturbance, UMN leg and LMN arm signs, bladder and bowel features

Question 30

What are the differentials for cervical spondylosis?

Answer 30

``` Acute hernia Spinal mets Multiple myeloma Fibromyalgia Ankylosing spondylitis Rheumatoid arthritis ```

Question 31

How is cervical spondylosis managed?

Answer 31

Analgesia - NSAID's Gentle exercise - physio Interlaminar cervical epidural injections Surgical decompression Radiculopathy - above + corticosteroids Myelopathy - urgent referral, decompression or immobilisation if not fit for surgery

Question 32

What investigation should be done for cervical spondylosis?

Answer 32

Cervical MRI if no improvement at 4-6 weeks | Immediately if red flag signs

Question 33

Where can spondylosis also affect?

Answer 33

Lumbar - back pain, stiffness, leg claudication of buttocks and legs Symptoms worse in morning

Question 34

What is syringomyelia?

Answer 34

Collection of CSF within spinal cord

Question 35

What causes syringomyelia?

Answer 35

Chiari malformation Trauma Tumours Idiopathic

Question 36

How does syringomyelia present?

Answer 36

Cape like loss of sensation to temperature Preservation of light touch, proprioception and vibration Classic example - pt burn hands without realising

Question 37

What other signs and symptoms are associated with syringomyelia?

Answer 37

``` Spastic weakness Paraesthesia Neuropathic pain Upgoing plantars Bladder and bowel dysfunction ```

Question 38

What complications are associated with syringomyelia?

Answer 38

Scoliosis Horners Syringobulbia is similar - fluid filled cavity within medulla of brainstem. Often extension of syringomyelia

Question 39

How is syringomyelia investigated?

Answer 39

Full spine MRI with contrast - exclude tumour or tethered cord Brain MRI - exclude chiari malformation

Question 40

How is syringomyelia managed?

Answer 40

Treat underlying cause | Shunt can be placed into syrinx if persistent