Spinal cord compression and cauda equina syndrome

Question 1

Vertebrae in which the spinal cord is found

Answer 1

C1 (junction with medulla) to L1 (conus medullaris)

Question 2

At what level would you take a lumber puncture

Answer 2

L4

Question 3

Below L1 are the lumber and sacral nerve roots - grouped together, what is this called

Answer 3

Cauda equina

Question 4

Deine paraplegia

Answer 4

Paralysis of BOTH legs always caused by spinal cord lesion

Question 5

Define hemiplegia

Answer 5

Paralysis of ONE side of body caused by lesion of he brain

Question 6

Signs of UMN lesion

Answer 6

Signs contralateral to lesion
Increased muscle tone (Spasticity)
Weakness (flexors generally weaker than extensors in legs and reverse in arms)
Increased reflexes, they are brisk - Hyperreflexia

Question 7

Signs of LMN lesion

Answer 7

Signs ipsilateral to lesion
Decreased muscle tone
Wasting/Atrophy
Fasciculations possible 
Reflexes reduced or absent
Weakness (relating to areas supplied by peripheral nerves)

Question 8

What are fasciculations and what could they be a sign of

Answer 8

Spontaneous involuntary twitching

LMN lesion

Question 9

Give examples of how the level of the LMN problem can be inferred from accompanying symptoms

Answer 9

Back pain/sciatica suggest a root problem
Weakness of the biceps with absence of the biceps reflex with UMN signs in the legs suggests cord disease e.g. a disc prolapse at C5/C6 (LMN at this level and UMN below)

Question 10

What is spondylolisthesis

Answer 10

Slippage of one vertebra over the one below
Nerve root comes out ABOVE the disc therefore root affected will be the one BELOW the disc herniation e.g. L4/5 herniation leads to L5 nerve root compression

Question 11

What is spondylosis

Answer 11

Degenerative disc disease

Question 12

What is myelopathy

Answer 12

Spinal cord disease caused by spinal cord compression

Upper motor neurone signs e.g. spasticity, weakness, hyperreflexia

Question 13

What is radiculopathy

Answer 13

Caused by spinal root compression
Lower motor neurone signs e.g. decreased muscle tone, wasting, weakness and fasciculations
Pain down dermatome supplied by root
Weakness in myotome supplied by root
No UMN signs

Question 14

Signs of acute radiculopathy (spinal root compression with no UMN signs)

Answer 14

No LMN signs as fasciculations and wasting take time to develop

Question 15

Spinal root of Clavicle dermatome

Answer 15

C4

Question 16

Spinal root of Nipples dermatome

Answer 16

T4

Question 17

Spinal root of Medial side of arm dermatome

Answer 17

T1

Question 18

Spinal root of Umbilicus dermatome

Answer 18

T10

Question 19

Spinal root of Anterior and inner leg dermatome

Answer 19

L2-3

Question 20

Spinal root of Knee dermatome

Answer 20

L4

Question 21

Spinal root of Posterior and outer leg dermatome

Answer 21

L5, S1-2

Question 22

Spinal root of Perianal area dermatome

Answer 22

S4

Question 23

What is myelopathy

Answer 23

Compression of the spinal cord resulting in upper neurone signs and specific symptoms dependent on where compression is

Question 24

Aetiology of spinal cord compression

Answer 24

Vertebral body neoplasms (secondary malignancy)
Disc herniation
Degenerative disc
Disc prolapse
Rarer:
Infection e.g. epidural abscess
Haematoma e.g. warfarin
Primary spinal cord tumour e.g. glioma, neurobiroma

Question 25

What are the 2 parts of discs of the spinal column called

Answer 25

``` Nucleus pulposus Annulus fibrosus (surrounding) ```

Question 26

What is disc prolapse

Answer 26

When nucleus pulposus moves and presses against the annulus resulting in pressure on nerve root and pain. Can produce a bulge in the disc which can cause pressure on the nerve root and thus pain

Question 27

Clinical presentation

Answer 27

Progressive weakness of the legs with upper motor neurone pattern and eventual paralysis. Hours to days onset. Arms affected if lesion is above thoracic spine. Sensory loss below lesion.

Question 28

Most common cause of spinal cord compression

Answer 28

Vertebral body neoplasms (secondary to malignancy elsewhere e.g. lung, breast, prostate, myeloma, lymphoma)

Question 29

Gold standard for diagnosis of spinal cord compression

Answer 29

MRI | identifies the cause and site of cord compression

Question 30

Why should imaging for spinal cord compression not be delayed at all

Answer 30

Since irreversible paraplegia may follow if the cord is NOT decompressed

Question 31

Other investigations (other than MRI) for spinal cord compression

Answer 31

Biopsy/surgical exploration - may be required to identify the nature of any mass Screening blood tests - FBC, ESR, B12, U and Es, Syphilis serology, LFT, PSA CXR - if TB or malignancy (see primary tumour)

Question 32

Treatment of spinal cord compression

Answer 32

Surgical decompression of the cord. Correction of pathology. DEXAMETHASONE reduces oedema around the lesion. Refer to neurosurgeons.

Question 33

Treatment of spinal cord compression - epidural abscess

Answer 33

Surgical decompression | Antibiotics

Question 34

Examples of surgical decompression of spinal cord

Answer 34

Laminectomy - removal of lamina/spongy tissue between discs to relieve pressure and thus symptoms Microdiscectomy - removal of herniated tissue from disc

Question 35

What is the cauda equina

Answer 35

Bundle of nerve roots from the lumbar and sacral levels that branch off the bottom of the spinal cord (conus medullaris). Nerve roots caudal (distal) to the level of the termination of the spinal cord at L1/L2.

Question 36

When does the cauda equina start

Answer 36

L1/2 (more L1)

Question 37

Cauda equina syndrome epidemiology

Answer 37

Rare, occurring mainly in adults but can occur at any age Occurs in around 2% of herniated discs

Question 38

Most common cause of cauda equina syndrome

Answer 38

Lumbar disc herniation at L4/5 and L5/S1

Question 39

Aetiology/Risk factors of Cauda equina

Answer 39

``` Herniation of lumber disc (most commonly at L4/5 and L5/S1) Tumours/metastases Trauma Infection Spondylolisthesis Post-op haematoma ```

Question 40

Pathophysiology of Cauda equina

Answer 40

Nerve root compression CAUDAL to the termination of the spinal cord at L1/2 Usually large central disc herniations at L4/5 or L5/S1 levels Bladder function can be affected due to S1-5 nerve root compression

Question 41

Clinical presentation of cauda equina syndrome

Answer 41

``` BB SAFE Bilateral sciatica Saddle anaesthesia Bladder/bowel dysfunction Erectile dysfunction Variable leg weakness that is FLACCID & AREFLEXIC (LMN signs) ```

Question 42

*What is major difference in clinical presentation between cauda euqina and lesions higher up in the cord

Answer 42

Leg weakness is flaccid and Areflexic (LMN) | NOT spastic and hyperreflexic

Question 43

What is sciatica

Answer 43

Pain, numbness and a tingling sensation that radiates from lower back and travels down one of the legs to the foot and toes

Question 44

Cauda equina syndrome investigations

Answer 44

History and clinical examination with appropriate radiological investigation. MRI is preferred method for diagnosis and determine level of compression and any underlying cause. MRI scan is only way to exclude CES Further investigations for underlying cause and focusing on localised site of compression Urodynamic studies - may be required to monitor recovery of bladder function following decompression surgery

Question 45

Cauda equina syndrome differential diagnosis

Answer 45

Conus medullaris syndrome Mechanical back pain or prolapsed lumber disc Fracture of lumber vertebrae due to trauma Spinal tumour Spinal cord compression Peripheral neuropathy

Question 46

What is conus medullaris syndrome

Answer 46

Conus medullaris is located above the cauda equina at T12-L2; nerve root pain is less prominent and the main features are urinary retention and constipation

Question 47

Complications of cauda equina syndrome

Answer 47

Paralysis. Sensory abnormalities. Bladder, bowel and sexual dysfunction.

Question 48

Management of cauda equina syndrome

Answer 48

Immediate referral to neurosurgery to relieve pressure

Question 49

Tests of specific nerve roots: L5-S1

Answer 49

Knee flexion | Or Straight leg raising

Question 50

Tests of specific nerve roots: S1-S2

Answer 50

Ankle plantar flexion (downwards)

Question 51

Tests of specific nerve roots: L4

Answer 51

Femoral stretch test

Question 52

Example surgical decompression to remove causative agent in cauda equina synrome

Answer 52

Microdiscectomy Epidural steroid injection (more effective for leg pain) Surgical spine fixation (if vertebrae slipped) Spinal fusion (reduces pain from motion and nerve root inflammation)

Question 53

What is microdiscectomy

Answer 53

Removal of part of disc (may tear dura)

Question 54

50yr old nurse comes in with longstanding back pain and pain radiating down right leg to sole of right foot. On examination there is weak plantar flexion, absent right ankle jerk, decreased sensation over lateral edge and sole of right foot WHERE IS LESION?

Answer 54

Sciatica | Right S1 lesion due to disc prolapse placing pressure on root