Spinal Symposium

Question 1

outline some elements of a single vertebrae…

Answer 1

vertebral body – WB surface, spinal formamen – conating the cord and later the spinal nerve roots, posterior elements, lamina superior and inferior articular procsess, Pedicles, spinous prcess and trasverese prcoess- allow muscle attachments

Question 2

think about lordosis and kyphosis, which is which?

Answer 2

lordosis=), kyphosis = (. Thoracic is mainly kyphotic, cervical and lumbar are mainly lordotic (L=L)

Question 3

what is the erector spinae?

Answer 3

long group of muscles composed of iliocostalism longismius and spinalis

Question 4

where dos the spinal cord end and what is this called?

Answer 4

L1 - conus medularis

Question 5

what is a dermatome?

Answer 5

A dermatome is an area of skin that is mainly supplied by a single spinal nerve

Question 6

What is a myotome?

Answer 6

A myotome is the group of muscles that a single spinal nerve innervates

Question 7

point outthe dermatomes of the arm on yourself…

Answer 7

clavicle=c4, lateral upper arm = c5, lateral forearm/thumb and index finger = c6, middle finger=c7, ring and pinky= c8, medial forearm = t1

Question 8

point outthe dermatomes of the leg on yourself…

Answer 8

front goes down from L1 to L5, where L4 covers the majority of the leg and knee, L3 and L2 groin as well, L5 majority of the dorsal foot. Back mainly s1 and s2, L5 is the heel, s1-s5 gets closer to the anus.

Question 9

what are the Myotomes for the upper limbs?

Answer 9

C5 - Shoulder abduction (deltoid), C 6 - Elbow flexion/ Wrist extensors (biceps), C 7 - Elbow extensors (triceps), C 8 - Long finger flexors (FDS/FDP), T 1 - Finger abduction (interossei)

Question 10

what are the myotomes for the lower limbs?

Answer 10

L2 - Hip flexion (iliopsoas), L3,4 - Knee extension (quadriceps), L4 - Ankle dorsiflexion (tib ant), L5 - Big toe extension (EHL), S1 - Ankle plantar flexion (gastroc)

Question 11

look at this card for myotomes and reflexes…..

Answer 11

Question 12

what is found on examination of complete spinal cord injury?

Answer 12

no motor or sensory function distal to lesion, no anal squeeze, no sacral sensation, ASIA Grade A, no chance of recovery

Question 13

what is found on examination of incomplete spinal cord injury?

Answer 13

some function left, more favourable prognosis

Question 14

what scale/classification is used to grade spinal injury on examination?

Answer 14

ASIA Classification

Question 15

give 5 patterns of spinal cord injury

Answer 15

tetraplegia, paraplegia, central cord syndrome, anterior cord syndrome, brown sequard syndrome.

Question 16

What is Quadra/Tetraplegia?

Answer 16

Partial or total loss of use of all four limbs and the trunk, Loss of motor/sensory function in cervical segments of the spinal cord.

Question 17

what are the consequences of tetraplegia when there is a cervical fracture?

Answer 17

Respiratory failure due to loss of innervation of the diaphragm, Phrenic nerve C3-5, ‘C5 keeps you alive’, Spasticity

Question 18

what is spasticity and when does it occur?

Answer 18

increased muscle tone, UMN lesion, spinal cord and above (CNS), injuries above L1

Question 19

what is Paraplegeia?

Answer 19

Partial or total loss of use of the lower-limbs , Impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord, Arm function spared, Possible impairment of function in trunk,

Question 20

consequences of thorcic/lumb fractures leading to Paraplegia?

Answer 20

Associated chest or abdominal Injuries, Spasticity if injury of spinal cord (i.e. above L1), Bladder/ Bowel function affected

Question 21

outline Central cord syndromes?

Answer 21

Older patients (arthritic neck), Hyperextension injury, Centrally cervical tracts more involved, Weakness of arms, still power in legs so can walk, Perianal sensation & lower extremity power persevered

Question 22

outline anterior cord syndrome?

Answer 22

Hyperflexion injury, Anterior compression fracture, Damaged anterior spinal artery, Fine touch and proprioception preserved, Profound weakness, poor prognosis of recovery

Question 23

Brown-sequard syndrome…

Answer 23

Hemi-section of the cord, Penetrating injuries, Paralysis on affected side (corticospinal), Loss of proprioception and fine discrimination (dorsal columns), Pain and temperature loss on the opposite side below the lesion (spinothalamic)

Question 24

How are spinal cord injuries Managed?

Answer 24

Prevent secondary insult ABCD with ATLS measures (advanced trauma life support) airway (control c spine), breathing (vent, o2), circulation (hp, hr, ivfluids, vasopressors), Disability (neurological function, PR, perianal sensation, log rolling), Imaging (xrays, ct, MRI)

Question 25

what is classified as neurogenic shock?

Answer 25

Hypotension, Bradycardia, Hypothermia, Injuries above T6, Secondary to disruption of sympathetic outflow

Question 26

what is classified as spinal shock?

Answer 26

Transient depression of cord function below level of injury, Flaccid paralysis, Areflexia, Last several hours to days after injury

Question 27

after mx with surgical fixation what is the Long-term mx?

Answer 27

Physiotherapy, Occupational therapy, Psychological support, Urological /Sexual counseling

Question 28

outline the anatomy of iv discs (type of joint, annulus fibrosus, nucleus pulposus)

Answer 28

Secondary Cartilaginous Joint, Disc is largest avascular structure in the body Annulus fibrosus - Tough outer layer/ Nucleus pulposus - Gelatinous core consisting mainly of water, collagen and proteoglycans, Annulus may tear and nucleus prolapse, Can cause cord / nerve root compression Cartilaginous end plate of each disc attaches to bony endplate of vertebra The ALL and PLL connect discs with vertebral bodies The fibres of the annulus fibrosis (collagen) run obliquely and alternately between layers - They resist rotational movements = Discs fail with twisting movements

Question 29

what direction do disc prolapses occur in usually?

Answer 29

postero-laterally

Question 30

what is the normal aging process of ivdiscs?

Answer 30

decreased water content, disc spaxce narrowing, degenerative cvhanges on xray and in the facet joint. Aggrevated by smoking etc.

Question 31

pathological processes on the ivdiscs…

Answer 31

Tearing of annulus fibrosis and protrusion of the nucleus, Nerve root compression by osteophytes, Central spinal stenosis Abnormal movement - Spondylolysis - Spondylolisthesis

Question 32

what are the types of disc problems?

Answer 32

bulge (generalised - common, asymptomatic), protrusion (annulus still intact but weak), extrusion (through the annulus but in continuity), sequestration (dessicated disc material free in the canal)

Question 33

what is the most common site of cervical prolapse?

Answer 33

c5/c6

Question 34

what is the most common site of thoracic prolapse?

Answer 34

t11/t12 - central, posterolateral and lateral herniations

Question 35

what is the most common site of lumbar prolapse?

Answer 35

l4/l5, l5/s1 - posterolateral, central disc may give pain in both legs or may be back pain only

Question 36

what motor, sensory and reflex change does l5/s1 cause?

Answer 36

sensory loss of little toe and sole of foot, motor weakness of plantar flexion of the foot, change in ankle jerk reflex

Question 37

what motor, sensory and reflex change does l4/l5 cause?

Answer 37

sensory loss of great toe and 1st dorsal webspace, motor weakness of EHL

Question 38

what motor, sensory and reflex change does l3/l4 cause?

Answer 38

sensory loss of medial apect of lower leg, motor loss of quads, change in knee jerk reflex

Question 39

outline cauda equina syndrome cause…

Answer 39

central lumbar disc prolapse/tumour/ trauma/ infection/ iatrogenic causes compression, surgical emergency, sacral nerve roots compressed – can result in permanent bladder and anal sphincter dysfunction and incontinence

Question 40

sy/sx of cauda equina syndrome

Answer 40

Injury or precipitating event, Location of symptoms (bilat buttock & leg pain + varying dysaethesiae + weakness – beware), Bowel or bladder dysfunction (urinary retention +/- incontinence overflow), PR exam - saddle anaesthesia (perianal loss of sensation), loss of anal tone & anal reflex, High index of suspicion in spinal post-op patients with increasing leg pain in presence of urinary retention

Question 41

what is spondylosis (OA)?

Answer 41

degenerative change at facet joints, discs, ligaments, if severe it can compress the whole cord not just the nerve roots causing myelopathy (UMN signs in limbs - increased tone, brisk reflexes)

Question 42

name the ligaments of the spine

Answer 42

Anterior Longitudinal Ligament (ALL – along the front of the vertebral bodies – broad, strong), Posterior Longitudinal Ligament (PLL – along the backs of the vertebral bodies, i.e. front of the spinal canal; narrower), Ligamentum Flavum (between laminae), Interspinous and Supraspinous Ligaments (between spinous processes), Intertransverse Ligament

Question 43

what are the features of spinal claudication?

Answer 43

Usually bilateral, Sensory dysaesthesiae, Poss weakness (drop foot – tripping), Takes several minutes to ease after stopping walking, Worse walking down hills because the spinal canal becomes smaller in extension, better walking uphill or riding bicycle

Question 44

types of spinal stenosis and their tx…

Answer 44

Lateral recess stenosis - nerve root injection, epidural, surgery, central stenosis - same, foraminal stenosis - same

Question 45

CASE 1…

Answer 45

56f, neck pain, 6 months of worsening numbness in the hand, Difficulty doing buttons, Wide based gait. Do a hx and exam, could be cervical myelopathy.

Question 46

CASE 2…

Answer 46

A 70 year old man presents with a “tired feeling” in both thighs which is precipitated by walking and relieved by rest. He has a long history of backache. Ddx - spinal stenosis, peripheral vascular disease, tell the difference between the two by risk factor assessment and distribution, examine pulses

Question 47

CASE 3…

Answer 47

A 70 year old lady presents with severe, worsening thoracic and lumbar back pain over several moths. No history of trauma, pain worse on standing but still present when lying in bed at night. History of weight loss. Important diagnosis to include are infection (discitis) or metastatic malignancy to the spine.