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Flashcards in Spine orthopaedics and trauma Deck (57):
1

Which myotome facilitates hip flexion?

L1/2

2

Which myotome facilitates knee flexion?

L3/4

3

Which movements does the L5 myotome facilitate?

Foot dorsiflexion and extensor hallicus longus

4

Which myotome facilitates plantarflexion?

S1/2

5

What is sciatica?

Buttock and/or leg pain in a specific dermotomal distribution accompanied by neurological disturbance

6

What is shown on this MRI?

Q image thumb

Slipped disc

7

What is a slipped.herniated disc?

A tear in the annulus fibrosis of an intervertebral disc allows the nucleus pulposis to bulge out beyond the damaged outer rings

8

What are some of the causes of disc herniation?

Age-related degeneration

Trauma

Lifting injuries

Straining

9

What direction is spinal disc herniation usually in and why?

Postero-laterally

The presence of the posterior longitudinal ligament prevents the disc from herniating directly posteriorly

10

What is the presentation of an acute disc tear?

Typically occurs after lifting heavy object

Acute onset back pain

Worse on coughing

11

How does sciatica present?

 Lower back pain

Buttock pain and numbness

Pain or weakness in various parts of the leg and foot 

"pins and needles"

Tingling and difficulty moving or controlling the leg

12

What causes sciatica?

Compression or irritation of one of the five nerve roots of the sciatic nerve e.g. by a herniated disc causing compression

 

13

How is disc prolapse managed?

Conservatively intially

Consider surgery if not resolving after 3 months

Surgery is to treat leg pain

14

How is backache managed conservatively?

Anti-inflammatory and/or muscle  relaxant
Physiotherapy

Xray
Return to normal activity
 

15

What are the red flag symptoms with back pain?

First back pain age <20 or >50
Non-mechanical, constant pain

History of cancer

History of steroids
Systemic upset/weight loss
Structural deformity
Saddle anaesthesia/paraesthesia and loss of bowel and bladder control
Severe pain longer than 6 weeks
 

16

What is cauda equina syndrome?

A serious neurologic condition in which damage to the cauda equina causes acute loss of function of the lumbar plexus

17

How does mechanical back pain present?

Recurrent relapsing and remitting back pain with no neurological symptoms
Worse on movement, relieved by rest

Aged between 20-60 and have had previous 'flare ups'

18

What are some of the causes of mechanical back pain?

Obesity

Poor posture

Poor lifting technique

Lack of physical activity

Depression

Degenerative disc prolapse

Facet joint OA

Spondylosis

19

What is spondylolysis?

The intervertebral discs lose water content with age resulting in less cushioning and increased pressure on the facet joints leading to secondary OA

20

Why is bed rest not advised in mechanical back pain?

This will lead to stiffness and spasm of the back which may exacerbate disability

21

What are the symptoms of an L3/L4 prolapse and what nerve is compressed?

L4 root entrapped

Pain down to medial ankle (L4), loss of quadriceps power, reduced knee jerk

22

What are the symptoms of an L4/L5 disc prolapse and which nerve is compressed?

L5 nerve root entrapment

Pain down dorsum of foot

Reduced power Extensor Hallucis Longus and tibialis anterior

23

What are the symptoms of an L5/S1 prolapse and which nerve is compressed?

S1 nerve root entrapment

Pain to sole of foot, reduced power planarflexion, reduced ankle jerks

24

What is spinal stenosis?

When the cauda equina of the lumbar spine has less space due to a combination of bulging discs, bulging ligamentum flavum and osteophytosis

25

What is the primary symptom of spinal stenosis?

Claudication

26

How does spinal claudication differ from vascular claudication?

The claudication distance is inconsistent

The pain is burning (rather than cramping)

Pain is less walking uphill (spine flexion creates more space for the cauda equina)

Pedal pulses are preserved

27

What are the symptoms of cauda equina syndrome?

Bilateral leg pain

Paraesthesiae or numbness and complain of “saddle anaesthesia”

Urinary retention/incontience

Constipation/bowel incontinence

28

What is the management of cauda equina syndrome?

Urgent MRI

Urgent discectomy

29

How are osteoporotic fractures of the lumbar spine managed?

Usually conservatively

30

What cervical spine pathology are children with Down's syndrome at risk of developing?

Atlanto‐axial (C1/C2) instability with subluxation potentially causing spinal cord compression

31

How is atlanto-axial instability screened for in Down's syndrome?

Screening with flexion‐extension xrays will demonstrate the abnormal motion

32

How does atlanto-axial instability occur in RA patients?

Destruction of the synovial joint between the atlas and the dens and rupture of the transverse ligament

33

What criteria must be met in order to clinically clear a C-spine?

No history of loss of consciousness

GCS 15 with no alcohol intoxication

No significant distracting injury (such as head injury, chest trauma or other fractures including more distal spinal fractures)

No neurological symptoms in the upper or lower limbs

No midline tenderness on palpation of the c-spine

No pain on gentle active neck movement (ask the patient to gently flexed forward, then rotate to each side)

34

Which C-spine fractures may be fatal?

High - especially C3 and above (phrenic nerve)

35

Do osteoporotic thoracolumbar wedge fractures require any surgery?

No

36

What proportion of thoracolumbar wedge fractures have associated neurological problems?

15-20%

37

What are the indications for surgical repair of thoracolumbar spinal fractures?

Presence of neurological deficit especially if progressive or very unstable injury

Unstable injury pattern with substantial loss of  vertebral height, displacement or involvement of the posterior ligamentous structures

38

How can stable injuries of the thoracic spine be treated and what are they protecting?

A brace to limit flexion and prevent kyphosis

39

How might more stable lumbar lordosis fractures be treated?

A plaster jacket to preserve the lumbar lordosis

40

What is 'spinal shock'?

A physiologic response to injury with complete loss of sensation and motor function and loss of reflexes below the level of the injury

41

How long does it usually take for spinal shock to resolve?

Roughly 24 hours

42

What is the bulbocavernous reflex?

A reflex contraction of the anal sphincter with either a squeeze of the glans penis, tapping the mons pubis or pulling on a urethral catheter

43

How is the bulbocavernous reflex used clinically?

It is absent in spinal shock

Its return signals the end of spinal shock

44

When does neurogenic shock occur?

Secondary to temporary shutdown of sympathetic outflow from the cord from T1 to L2

Usually due to injury to the cervical or upper thoracic cord 

45

What are the symptoms of neurogenic shock?

 Hypotension and bradycardia which usually resolves within 24‐48 hours

Priaprism may be present due to unopposed parasympathetic flow

46

How is neurogenic shock treated?

IV fluid therapy

47

How can spinal cord injuries be classified?

Complete or incomplete

48

What is complete spinal cord injury?

Complete spinal cord injury results in no sensory or voluntary motor function below the level of the injury (reflexes should return)

49

How is the level of the injury (spinal cord) determined?

The most distal spinal level with partial function (after spinal shock has resolved) as determined by the presence of dermatomal sensation and myotomal skeletal muscle voluntary contraction

50

What is the prognosis for recovery from complete spinal cord injury?

Poor

51

What are incomplete spinal cord injuries?

Injuries with some neurologic function (sensory and/or motor) is present distal to the level of injury

52

What signs are indicators of continuity of motor and sensory tracts in the distal spinal cord?

Sacral sparing with preservation of perianal sensation, voluntary anal sphincter contraction and big toe flexion (FHL muscle, S1/2)

53

When might ventilatory support be required in spinal cord injury?

Loss of intercostal muscle function (T1-12)

54

What is central cord syndrome?

A form of cervical spinal cord injury characterised by loss of motor and power and sensation in the arms and hands

55

Why are the arms more paralysed than the legs in central cord syndrome?

The upper limb supply tends to be more to the center of the spinal cord

56

How does central cord syndrome typically occur?

A hyperextension injury in a cervical spine with osteoarthritits

57

What is Brown-Sequard syndrome?

An incomplete spinal cord injury characterised by ipsilateral paralysis and loss of dorsal column sensation occurs with contralateral loss of pain, temperature and coarse touch sensation