Spinal cord and root dysfunction

Question 1

Possible presentations

Answer 1

Pain
Sensory disturbance 
Weakness 
Sphincter dysfunction
Sexual dysfunction

Question 2

Management of spinal problems - surgery is first line in most cases. True or false?

Answer 2

False

- try 6 weeks of physiotherapy and if symptoms are persistent, patient should be sent for MRI scan

Question 3

Central problem (something pressing on the spinal cord itself) then what are the likely symptoms?

Answer 3

UMN problem

• increased tone
• no weakness
• brisk reflexes
• upgoing plantars
• no fasciculations

Question 4

Lateral problem (something pressing on the nerve roots/plexus/peripheral nerve) then what are the likely symptoms?

Answer 4

LMN problem

• weakness
• atrophy
• decreased tone
• absent reflexes
• fasciculations

Question 5

Arm involvement if the problem is in which of the following regions:

• cervical
• thoracic
• lumbar

Answer 5

Cervical

Question 6

Leg involvement if the problem is in which of the following regions:

• cervical
• thoracic
• lumbar

Answer 6

Lumbar

Question 7

Which nerve root is affected: disorder of elbow flexion?

Answer 7

C5

Question 8

Which nerve root is affected: disorder of wrist extension?

Answer 8

C6

Question 9

Which nerve root is affected: disorder of finger flexion?

Answer 9

C8

Question 10

Which nerve root is affected: disorder of knee extension?

Answer 10

L3

Question 11

Which nerve root is affected: disorder of elbow extension?

Answer 11

C7

Question 12

Which nerve root is affected: disorder of finger abduction?

Answer 12

T1

Question 13

Which nerve root is affected: disorder of hip flexion?

Answer 13

L2

Question 14

Which nerve root is affected: disorder of ankle plantar flexors ?

Answer 14

S1

Question 15

Which nerve root is affected: Disorder of ankle dorsiflexion?

Answer 15

L4

Question 16

Which nerve root is affected: disorder of long toe extension?

Answer 16

L5

Question 17

Red flags in a back pain history

Answer 17

Pain for longer than 6 weeks
Bilateral leg pain 
Pain troublesome at night 
New neurological deficit 
Systemic upset 
Saddle anaesthesia 
Bladder/bowel changes 
Weight loss 
Hx cancer 
Age under 20 
Age over 60

Question 18

Bilateral leg pain, loss of bowel control, saddle anaesthesia, painless urinary retention with overflow incontinence. What is the likely diagnosis?

Answer 18

Cauda equinae syndrome

Question 19

Cauda equinae syndrome - definition

Answer 19

Something causes compression on all of the nerve roots of the cauda equine region.
This is a surgical emergency

Question 20

Cauda equinae syndrome - causes of compression

Answer 20

Prolapsed lumbar disc - central prolapse
Tumour compression
Trauma
Infection

Question 21

Cauda eqinae syndrome - clinical examination

Answer 21

PR exam

Question 22

Cauda equinae syndrome - what urgent imaging investigation must be carried out

Answer 22

MRI lumbosacral spine

- necessary to determine the level of prolapse

Question 23

Cauda equina syndrome - management

Answer 23

Urgent surgery to remove the material that is compressing the nerves - discectomy

Question 24

Patient who has been lifting heavy suitcases presents with back pain. What is the likely diagnosis?

Answer 24

Intervertebral disc prolapse

- slipped disc

Question 25

Intervertebral disc prolapse - definition

Answer 25

Tear in the outer annulus fibrosis of an invertebrate disc

Question 26

Intervertebral disc prolapse - how can you determine the exact location of the prolapse?

Answer 26

Analyse the myotomes and dermatomes

Question 27

Intervertebral disc prolapse - initial management

Answer 27

Conservative management - bed rest - anti-inflammatory - muscle relaxant - make sure patient remains mobile

Question 28

Intervertebral disc prolapse - when would you consider surgery

Answer 28

Patient isn't getting better after 3 months of conservative treatment

Question 29

What are the 2 most common locations for lumbar disc prolapse?

Answer 29

L4/L5 level | L5/S1 level

Question 30

Spinal claudication - who gets it

Answer 30

Over 50 | male

Question 31

Name 2 causes of spinal claudication?

Answer 31

Manual worker | Obesity

Question 32

Spinal claudication - distribution of pain

Answer 32

Dematomal distribution down bilateral legs

Question 33

Spinal claudication - pain is worse at rest/ with movement?

Answer 33

With movement

Question 34

Patient who experiences leg pain which is relieved when walking up a hip as they are more hunched over (spine flexion). What is the likely diagnosis?

Answer 34

Spinal claudication

Question 35

Spinal claudication - investigations?

Answer 35

MRI scan - lumbar spinal stenosis (squished spinal canal) - buldges present at several levels

Question 36

Spinal claudication - management if patients symptoms are intolerable

Answer 36

Elective surgery (lumbar spinal compression)

Question 37

How to tell the difference between spinal claudication and vascular claudication?

Answer 37

Check peripheral pulses: - if pulses are normal = spinal claudication - if pulses are diminished/absent = vascular claudication

Question 38

Cervical myelopathy - definition

Answer 38

Central disc prolapse in the cervical spine. Therefore, UMN signs are present

Question 39

Cervical myelopathy - clinical features

Answer 39

``` Hands are usually affected first usually bilateral paraesthesia numbness difficulty with fine motor tasks dropping objects ```

Question 40

Cervical myelopathy - investigations

Answer 40

MRI cervical spine

Question 41

Cervical myelopathy - management

Answer 41

Decompressive cervical surgery to prevent the condition from deteriorating further

Question 42

Cervical spondylosis - definition

Answer 42

Degenerative arthritic process involving cervical spine and affecting intervertebral disc

Question 43

Cervical spondylosis - imaging investigations show

Answer 43

Osteophytes

Question 44

Causes of acute spinal cord compression

Answer 44

Trauma Tumours Infection

Question 45

Acute spinal cord compression - trauma - investigations

Answer 45

X ray CT scan MRI scan

Question 46

Acute spinal cord compression - trauma - management

Answer 46

Immobilise (neck brace) Decompress Stabilise (external fixation)

Question 47

Acute spinal cord compression - tumours - most common

Answer 47

Bony mets

Question 48

Acute spinal cord compression - tumours - management

Answer 48

IV dexamethasone Radiotherapy Chemotherapy

Question 49

Patient that has lost motor power on left side of body but on right side of body pain and temperature sensation is lost. What is this called?

Answer 49

Brown Sequard syndrome

Question 50

Brown Sequard syndrome - definition

Answer 50

``` Cord hemisection Affects - ipsilateral corticospinal tract - ipsilateral DCML tract - contralateral spinothalamic tract ```

Question 51

Central cord syndrome - who gets it?

Answer 51

Old patients who fall over

Question 52

Central cord syndrome - pathophysiology

Answer 52

Inner part of the spinal cord is injured but the outer part is fine

Question 53

Central cord syndrome - clinical features

Answer 53

Signs that patient has fallen Distal upper limb weakness Hands are paralysed/weak Lower limb power is preserved

Question 54

Central cord syndrome - management

Answer 54

Leave it alone and it gets better

Question 55

Chronic spinal cord compression - LMN signs predominate. True or false?

Answer 55

False | - UMN signs predominate

Question 56

Patient presents with bilateral weakness of the limbs. The upper limbs are more affected than the lower limbs. What is the likely diagnosis? - anterior cord syndrome - central cord syndrome - posterior cord syndrome

Answer 56

Central cord syndrome

Question 57

In central cord syndrome, why are the upper limbs more affected than the lower limbs?

Answer 57

In the corticospinal tracts, the upper limbs are represented medially and the lower extremities are laterally

Question 58

Patient presents with bilateral weakness and loss of pain and temperature sensation. Proprioception, vibratory sense and light touch are preserved. What is the likely diagnosis? - anterior cord syndrome - central cord syndrome - posterior cord syndrome

Answer 58

Anterior cord syndrome