Spinal Cord and Root Dysfunction Flashcards by Kerry Hendrie

List the symptoms associated with dysfunction of the spinal cord and roots

Pain
Sensory disturbance
Weakness
Sphincter dysfunction
Sexual dysfunction

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A lesion of the spinal cord affecting the cervical level would present with…

Involvement of arms

UMN or LMN symptoms

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A lesion of the spinal cord affecting the thoracic level would present with…

Arms not/minimally involved

UMN or LMN features

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A lesion of the spinal cord affecting the lumbar level would present with…

Only legs involved

No UMN features

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For UMN lesions and LMN lesions, outline the weakness distribution respectively

Corticospinal CENTRAL distribution (weak extensory in arms and weak flexors in legs)
Generalized, predominantly proximal, distal or focal. No preferential involvement of corticospinal innervated muscles.

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For UMN lesions and LMN lesions, outline the pattern of sensory loss respectively

Central pattern

None - glove stocking, peripheral nerve or root distribution

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For UMN lesions and LMN lesions, outline the effect on deep tendon reflexes respectively

Increased/ brisk (unless very acute - flaccid)

Normal or decreased

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For UMN lesions and LMN lesions, outline the effect on muscle tone respectively

Increased

Normal or decreased

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For UMN lesions and LMN lesions, outline the effect on muscle bulk respectively

Sometime hypertrophy

Wasting

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What types of pathology cause UMN lesion?

LESION IN SPINAL CORD OR BRAIN
Stroke
SOL
Spinal cord problems

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What types of pathology cause LMN lesion?

LESION IN SPINAL NERVE (AFTER CN NUCLEUS)
MND
Spinal muscular atrophy (lead poisoning, poliomyelitis)

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Spinal cord dysfunction presenting with UMN symptoms suggests the position of the lesion is where on the spinal cord?

Central

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Spinal cord dysfunction presenting with LMN symptoms suggests the position of the lesion is where on the spinal cord?

Lateral

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Brisk reflexes of the lower limb would suggest the lesion is coming from the lumbar spinal cord only? True/ False?

False

No lumbar spinal cord involvement as there is no UMN features at this level

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For UMN lesions and LMN lesions, state whether fasciculations are present, respectively

Absent

Present

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For UMN lesions and LMN lesions, outline the plantar response for each, respectively

Upgoing

Downgoing

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For UMN lesions and LMN lesions, state whether clonus is present, respectively

Present

Absent

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Which chart allows you to localise spinal cord lesions via dermatomes and myotomes?

ASIA chart

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Which clinical symptoms would be suggestive of a cervical disc prolapse?

Arm pain
Depends on level of lesion - think dermatomes and myotomes 
Numbness/ tingling along dermatome
Weakness along myotome
LMN symptoms

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Which clinical symptoms would be suggestive of a thoracic disc prolapse? What is a common cause?

Thoracic pain
Depends on level of lesion - think dermatomes and myotomes
Numbness/ tingling along dermatome
Weakness along myotome
Central causing myelopathy

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Which clinical symptoms would be suggestive of a lumbar disc prolapse?

Leg pain
Depends on level of lesion - think dermatomes and myotomes
Numbness/ tingling along dermatome
Weakness along myotome
LMN symptoms

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Spinal claudication symptoms are typically continuous. True/ False?

False

Typically intermittent

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List an exacerbating and relieving factor for spinal claudication

Mobilisation

At rest and bending forward (flexion) - ARTHROPOID posture

List clinical features suggestive of spinal claudication

Dull achy pain (typically back of thighs/ calves)
Altered sensation
Heaviness/ weakness of limbs

How does spinal claudication appear on imaging?

Whole canal is squashed and ligaments surround the canal are thick

Chronic spinal claudication leads to...

Spinal stenosis

What clinical feature would be more suggestive of vascular rather than spinal claudication? What investigation can be done to differentiate?

Absent peripheral pulses | ABPI

What is cauda equina syndrome?

Emergency condition in which there is massive disc prolapse compressing all lumbosacral spinal roots

How is cauda equina diagnosed?

MRI scan and PR exam

Which clinical features are suggestive of cauda equina syndrome?

``` Bilateral leg pain (can resolve) - S1 Perianal sensory loss to pinprick Genital numbness Erectile dysfunction Painless urinary retention with overflow incontinence (no control or urgency) - S2-4 ```

List the red flag symptoms used for spinal conditions

``` Bilateral leg pain Thoracic back pain Weight loss, night sweats, fever Night pain Sphincter disturbance Perianal sensory loss Age <20 or >55 History of carcinoma Immunocompromised Progressive neurological deficit Trauma ```

What is cervical myelopathy? Is it reversible?

Central disc prolapse in cervical spine, typically irreversible

What are the presenting symptoms in a patient with cervical myelopathy?

``` Finger tip paraesthesia progressing to 'numb clumsy hands' - usually bilateral Difficulty with fine motor tasks Dropping objects Reduced mobility (FALLS) Hypereflexia (legs jump at night) ```

What two clinical signs should be checked for if cervical myelopathy is suspected?

UMN: Hoffman sign: Finger reflex whereby flicking of the nail on the middle finger leads to flexion of the ipsilateral thumb Lhermittes sign: Sudden sharp electric shock down all four limbs, especially on head movement

Treatment for radiculopathy e.g. sciatica is typically conservative. True/ False?

True | Patients do not require surgery

List some complications of spinal surgery

``` Pain Bleeding Infection CSF leak Instability Nerve injury/ paralysis Failed back syndrome Medical risks (DVT/ PE, chest, MI, drug reactions) Cauda equine syndrome Risk to life ```

Outline the clinical features of failed back syndrome

``` Recurrence, residual compression Nerve injury Altered joint mability/ instability Fibrosis/ arachnoiditis Infection ```

List the main risk factors for failed back syndrome

Depression/ anxiety Diabetes Smoking High BMI

Outline management options for failed back syndrome

``` Reoperation? Antibiotics if infection Anti-inflammatories Anti-depressants Physio CBT TENS Spinal cord stimulation Referral to chronic pain team ```

What type of fracture is caused by rapid flexion to the spine, common in RTAs?

Burst fracture - crush injury to disc

What acute spinal condition causes autonomic dysreflexia?

Spinal shock

How does an epidural haematoma appear on imaging?

Long collection posterior to spinal cord

A syrinx in the spinal cord is associated with what condition?

Syringomyelia - build up of CSF in spinal cord

How does a syrinx appear on imaging?

Hyperdense mass in the spinal cord

What is a chiari malformation?

Cerebellar tonsils displace downwards through the foramen mangnum

Name 2 groups of people who are likely to have a disc herniation

Young patients carrying a heavy load | Older patient with degeneration or spondylosis

A paramedian or posterolateral disc prolapse in L4/5 is likely to affect which nerve root?

L5 | Traversing nerve root below the disc

A lateral or extraforaminal disc prolapse in L4/5 is likely to affect which nerve root?

L4 | Exiting nerve root leaving at level of prolapse

What is a radiculopathy?

Dysfunction of nerve root resulting in dermatomal/ sensory deficit/weakness of muscle groups supplied

Outline the management of cauda equina syndrome

Disectomy for herniated disc Decompression and fixation for fracture Haematoma evacuation

How is spinal stenosis managed?

Conservation (physio, analgesia) 1st line | Laminectomy 2nd line

What is cervical spondylosis? What can it lead to?

Reduction in water and fragmenting nucleus pulposus due to a degenerative arthritic process of cervical spine Radiculopathy - LMN Myelopathy - UMN

What is the age of onset for cervical spondylosis?

Over 50yo

How does cervical spondylosis appear on MRI scan?

Narrowing of disc space and osteophyte formation

Outline the management for cervical spondylosis

Laminectomy (multilevel posterior compression) Disectomy (anterior compression) Foraminectomy (unilateral root compression)