Mss 06: Functional Anatomy Of The Spine

Front 1

What is scoliosis?

Back 1

Abnormal lateral curvature of spine, abnormal rotation of one vertebra upon the other
--> genetic, trauma, idiopathic; adolescent girls more than boys

Front 2

What is kyphosis?

Back 2

Hunchback - accentuated flexion of thoracic spine --> poor spine, osteoporosis

Front 3

What is lordosis?

Back 3

Swayback - accentuated extension of lumbar spine --> weakened trunk muscles, late pregnancy, obesity

Front 4

What part of the axis (C2) is most commonly affected by a fracture? What are the types/degrees?

Back 4

Dens: 3 types -
I) fracture of tip - usually stable
II) fracture of base or neck - unstable
III) fracture extends into body of axis - reunite well when immobilized

Front 5

Besides the dens, what kind of fractures can happen to the axis (C2)?

Back 5

Hangman fracture - through neural arch / pedicle - can be stabilized, if survived with or w/o spinal cord damage

Front 6

What kind of fracture can happen to the atlas (C1)?

Back 6

Jefferson fracture - burst fracture of the atlas, often caused by a blow to the top of the head

Front 7

What is the most common type of arthritis?

Back 7

Osteoarthritis - erosion of articular cartilage of weight-bearing joints such as those in vertebral column

Front 8

What is the cause of osteoarthritis? Where?

Back 8

Progressive erosion of cartilage in joints of spine, fingers, knee, and hip (most common)

Front 9

What are the risk factors for Osteoarthritis?

Back 9

- Age
- Female sex
- Joint trauma
- Repetitive stress
- Obesity
- Genetic
- Race
- Previous inflammatory joint disease

Front 10

What are some potential complications of osteoarthritis?

Back 10

- In spine, involves IV discs and facet joints
- Leads to hyperextension deformity and spinal nerve impingement

Front 11

What is the most common bone disease?

Back 11

Osteoporosis (porous bone) - imbalance of bone resorption and formation, which places bones at a great risk for fracture

Front 12

What is the cause of Osteoporosis?

Back 12

- Postmenopausal women
- Genetics
- Vitamin D synthesis deficiency
- Idiopathic

Front 13

What are the risk factors for Osteoporosis?

Back 13

- Family history
- White female
- Increasing age
- Estrogen deficiency (menopause)
- Vitamin D deficiency
- Low Ca2+ intake
- Smoking
- Alcohol
- Inactive lifestyle

Front 14

What are the potential complications of Osteoporosis?

Back 14

- Vertebral compression fractures
- Fracture of proximal femur or humerus, ribs, and distal radius (Colles' fracture)

Front 15

What is Spondylolysis?

Back 15

Congenital defect or an acquired stress fracture of the vertebral lamina that presents w/ no slippage of adjacent articulating vertebrae (Scottie dog w/ collar)

Front 16

Where is the most common site of Spondylolysis and Spondylolisthesis?

Back 16

L5-S1

Front 17

What is Spondylolisthesis?

Back 17

Bilateral defect (complete dislocation) resulting in an anterior displacement of vertebral body and transverse process while posterior fragment remains in proper alignment over sacrum (Scotty dog w/ broken neck)

Front 18

What causes low back and lower limb pain in Spondylolisthesis?

Back 18

Pressure on spinal nerves

Front 19

What is the most common musculoskeletal disorder?

Back 19

Low back pain

Front 20

What are the most common causes of low back pain?

Back 20

- Intervertebral disc rupture and herniation
- Nerve inflammation or compression
- Degenerative changes in vertebral facet joints
- Sacroiliac joint and ligament involvement
- Metabolic bone disease
- Psychosocial factors
- Abdominal aneurysm
- Metastatic cancer
- Myofascial disorders

Front 21

What is responsible for back pain when there are changes in the vertebral facet (zygapophyseal) joints?

Back 21

- Sensory nerve fibers, derived from the dorsal rami of spinal nerves, supply the synovial linings of the capsules surrounding the joints
- Degeneration of the articular cartilage or osteophytes (bony outgrowths) of the facet articular processes can cause pain
- Responsible for ~15% of back pain

Front 22

What are the important vertebral joints?

Back 22

- Intervertebral joint (symphysis)
- Zygapophyseal (facet) joint

Front 23

What are the two components of the intervertebral disc?

Back 23

- Nucleus pulposus - central nuclear zone of collagen and hydrated proteoglycans - acts as shock absorber
- Anulus fibrosus - concentrentic lamellae of collagen fibers

Front 24

What can happen with repeated compression-relaxation cycles on intervertebral discs?

Back 24

- Peripheral tears of anulus fibrosus
- Extrusion and herniation of more gelatnious nucleus pulposus
- Often occurs w/ age as N.P. becomes more dehydrated, transferring more of the compression forces to the anulus fibrosus
- Causes thickening of anulus and tears

Front 25

What direction do most disc herniations occur in?

Back 25

- Posterolateral direction - because anulus fibrosus tears often occur at posterolateral margins of disc (rim lesions)
- Posterior longitudinal ligament reinforces the anulus, therefore posterior herniations are much less likely

Front 26

What would happen if the posterior longitudinal ligament wasn't supporting the anulus fibrosus?

Back 26

Disc herniations could occur posteriorly which could compress the spinal cord and nerve roots

Front 27

What are the most common sites for disc herniation? Implications?

Back 27

- Cervical: C5-C6, C6-C7 --> pain in shoulder/upper limb
** Lumbar: L4-L5, L5-S1 --> pain over SI joint, hip, posterior thigh, and leg

Front 28

What are the features of a L4-L5 disc herniation (impinging L5 nerve):
- Pain
- Numbness
- Weakness
- Atrophy
- Reflexes

Back 28

- Pain: over SI joint, hip, lateral thigh, and leg
- Numbness: lateral leg, first 3 toes
- Weakness: dorsiflexion of great toe and foot, difficulty walking on heels, foot drop may occur
- Atrophy: minor
- Reflexes: internal hamstring reflex diminished or absent

Front 29

What are the features of a L5-S1 disc herniation (impinging S1 nerve):
- Pain
- Numbness
- Weakness
- Atrophy
- Reflexes

Back 29

- Pain: SI joint, hip, postero-lateral thigh, leg to heel
- Numbness: back of calf, lateral heel, foot to toe
- Weakness: plantar-flexion of foot and great toe, difficulty walking on toes
- Atrophy: gastrocnemius and soleus
- Reflexes: ankle jerk diminished or absent

Front 30

What is the difference in weakness for L4-L5 vs L5-S1 disc herniation?

Back 30

- L4-L5: dorsiflexion of great toe and foot; difficulty walking on heels, foot drop
- L5-S1: plantarflexion of foot and great toe; difficulty walking on toes

Front 31

What is the difference in atrophy for L4-L5 vs L5-S1 disc herniation?

Back 31

- L4-L5: minor
- L5-S1: gastrocnemius and soleus

Front 32

What is the difference in reflexes for L4-L5 vs L5-S1 disc herniation?

Back 32

- L4-L5: diminished or absent internal hamstring reflex
- L5-S1: diminished or absent ankle jerk

Front 33

What are the most common causes of hip pain that are not actually from the hip?

Back 33

- Lumbar spine (herniated disc)
- Buttocks (bursitis or hamstring injury)
- Pelvic region (intrapelvic disorder)

Front 34

What is the largest nerve in the body?

Back 34

Sciatic nerve - composed of tibial and common fibular nerves

Front 35

What does the sciatic nerve provide motor innervation to?

Back 35

- Tibial component - posterior compartment of thigh (extensors at hip and knee flexors)
- Tibial and common fibular components - all muscles below knee

Front 36

What does the sciatic nerve carry sensory fibers from?

Back 36

- Posterior thigh
- Posterolateral leg
- Plantar surface of foot

Front 37

What are the key lumbar and sacral dermatomes?

Back 37

- L1: inguinal region
- L3: medial femoral condyle
- L4: anterior knee / medial malleolus
- L5: second toe / foot dorsum
- S1: lateral heel
- S2: popliteal fossa

Front 38

What nerve roots are responsible for HIP:
- Flexion?
- Extension?

Back 38

- Flexion: L2, 3
- Extension: L5, S1

Front 39

What nerve roots are responsible for KNEE:
- Flexion?
- Extension?

Back 39

- Flexion: L3, 4
- Extension: L5, S1

Front 40

What nerve roots are responsible for Ankle:
- Dorsiflexion?
- Plantarflexion?

Back 40

- Dorsiflexion: L4, 5
- Plantarflexion: S1, 2

Front 41

What nerve roots are responsible for foot:
- Inversion?
- Eversion?

Back 41

- Inversion: L4, 5
- Eversion: L5, S1

Front 42

What happens in "whiplash"? Cause?

Back 42

- Cervical hyperextension - stretched or torn cervical muscles and in severe cases, ligament, bone, or nerve damage
- Rear-end vehicular accident

Front 43

What are the ligaments of the vertebral column?

Back 43

- Anterior longitudinal ligament
- Posterior longitudinal ligament
- Ligamentum flavum
- Interspinous ligament
- Supraspinous ligament

Front 44

What are the key cervical dermatomes?

Back 44

- C4 - AC joint
- C5 - lateral antecubital fossa
- C6 - thumb
- C7 - middle finger
- C8 - little finger

Front 45

What are the key thoracic dermatomes?

Back 45

- T1 - median antecubital fossa
- T4 - nipple
- T10 - umbilicus (belly button)
- T12-L1 - inguinal / groin region

Front 46

What is the most common infection of the peripheral nervous system?

Back 46

Herpes Zoster (Shingles) - acute neuralgia confined to dermatome distribution of a specific spinal or cranial sensory nerve root

Front 47

What is the presentation of Herpes Zoster (Shingles)?

Back 47

- Vesicular rash confined to a radicular or cranial nerve sensory distribution
- Initial intense burning, localized pain w/ vesicles appears 72-96 hrs later

Front 48

What are the most common sites affected by Herpes Zoster (Shingles)?

Back 48

One or several contiguous dermatomes (T5-L2), CN V (semilunar ganglion), or CN VII (geniculate ganglion)

Front 49

Where do you do a lumbar puncture / deliver epidural anesthesia?

Back 49

- Subarachnoid space of lumbar cistern (lumbar puncture) or epidural space (epidural)
- Midline between L3 and L4 or L4 and L5 (around area of iliac crests)

Front 50

Where does the spinal cord end?

Back 50

L1/L2

Front 51

What causes spina bifida?

Back 51

Low folic acid ingestion during first trimester

Front 52

Where does spina bifida occur most frequently?

Back 52

L5 or S1

Front 53

What are the different degrees of Spina Bifida?

Back 53

- Occulta - missing neural arch of vertebra
- Meningocele - meninges and CSF protrude as cyst
- Meningomyelocele - meninges and cord itself protrude as cyst

Front 54

What are the neurologic symptoms related to spinal nerve root(s) or cord compression?

Back 54

- Extremity pain
- Numbness
- Tingling
- Weakness
- Bowel/bladder urgency/incontinence

Front 55

What diagnosis do you need to rule out when a patient presents with loss of bowel or bladder control?

Back 55

Myelopathy (spinal cord) or Stenosis (narrowing of spinal column)

Front 56

What diagnosis do you need to rule out when a patient presents with significant weakness?

Back 56

Myelopathy (spinal cord) or radiculopathy (nerve root)

Front 57

What diagnosis do you need to rule out when a patient presents with saddle anesthesia?

Back 57

Myelopathy (spinal cord) or Cauda Equina Syndrome

Front 58

What diagnosis do you need to rule out when a patient presents with chronic corticosteroid use?

Back 58

Compression fracture

Front 59

What diagnosis do you need to rule out when a patient presents with prior spine surgery?

Back 59

- Hardware failure
- Adjacent segment disease
- Recurrent disc herniation

Front 60

If a patient <40 yo presents w/ morning stiffness that improves w/ activity but not w/ rest, what should you suspect?

Back 60

Spondyloarthropathy - joint disease of the vertebral column

Front 61

What are the cervical spine physical landmarks?

Back 61

- C3: hyoid bone
- C4-5: thyroid cartilage
- C6: first cricoid ring
- C7: most prominent spinous process

Front 62

What are the lumbar/sacral spine physical landmarks?

Back 62

- L4/5: top of iliac crest
- S2: PSIS

Front 63

What pathologic reflexes would indicate an upper motor neuron process?

Back 63

- Hoffman - passive rapid flexion of middle finger distal phalynx (positive = flexion of thumb, index finger)
- Babinski - stroking sole of foot resulting in great to extension and toe spreading

Front 64

What is a myotome?

Back 64

Collection of muscle fibers innervated by the motor axons within each segmental nerve (root)

Front 65

How do you test motor innervation of important cervical / thoracic spinal nerves?

Back 65

- C5: biceps (elbow flexor)
- C6: extensor carpi radialis (wrist flexor)
- C7: triceps (elbow extensor)
- C8: flexor digitorum profundus (3rd) (distal finger flexor)
- T1: abductor digiti minimi (little finger abduction)

Front 66

How do you test motor innervation of important lumbar/sacral spinal nerves?

Back 66

- L2: ilipsoas (hip flexor)
- L3: quadriceps (knee extensor)
- L4: tibialis anterior (ankle dorsiflexor)
- L5: extensor hallicus longus (big toe extensor)
- S1: gastrocnemius (ankle plantarflexor)

Front 67

What are the important reflexes to test?

Back 67

- C5: biceps
- C6: brachioradialis
- C7: triceps
- L4: quadriceps (patellar)
- L5: medial hamstring
- S1: gastrocnemius (achilles)

Front 68

What is Lhermitte's sign? What is positive?

Back 68

Passive anterior cervical flexion elicits "electric-like" sensation down the spine or extremities --> implies cervical spinal cord pathology

Front 69

What is Spurling's sign? What is positive?

Back 69

Reproduction of radicular (nerve root) symptoms w/ cervical spine extension, rotation, and lateral flexion --> positive implies cervical nerve root pathology

Front 70

What is this testing?

Back 70

Lhermitte's sign - Passive anterior cervical flexion elicits "electric-like" sensation down the spine or extremities --> implies cervical spinal cord pathology

Front 71

What is this testing?

Back 71

Spurling's test - Reproduction of radicular (nerve root) symptoms w/ cervical spine extension, rotation, and lateral flexion --> positive implies cervical nerve root pathology

Front 72

What do you do in the straight-leg test / Lasegue sign? Positive?

Back 72

Patient lies supine while leg is raised w/ knee extended; stop raising leg when patient reports pain --> LEG pain reproduced at 30-70 degrees (implies lumbar nerve root pathology - L5/S1)

Front 73

If this elicits leg pain, what does this imply?

Back 73

Lumbar nerve root pathology (L5 or S1)

Front 74

What do you do in the femoral nerve stretch test? Positive?

Back 74

- Patient is placed in prone position while knee is flexed
- Positive: reproduce pain in anterior thigh
- Implies upper lumbar nerve root pathology (L2-L4)

Front 75

If this elicits leg pain, what does this imply?

Back 75

Upper lumbar nerve root pathology (L2-L4)

Front 76

If a patient has the following symptoms what should you be thinking of as the cause?
- Spasticity/hypertonicity
- Increased reflexes
- Positive pathological reflexes
- Extensor plantar response

Back 76

Upper Motor Neuron Injury
- Spinal cord injury
- Brain injury / stroke
- Myelopathy
- CNS lesion

Front 77

If a patient has the following symptoms what should you be thinking of as the cause?
- Flaccid weakness
- Loss of reflexes
- Muscle wasting and atrophy

Back 77

- Peripheral nerve entrapment
- Radiculopathy

Front 78

What are the red flags for when to suspect malignancy?

Back 78

- History of cancer
- Unexplained weight loss
- > 50 yo

Front 79

What are the red flags for when to suspect a spinal fracture?

Back 79

- Major trauma
- Minor trauma or strenuous lifting in older or potentially osteoporotic individual
- Prolonged corticosteroid use
- Osteoporosis
- Age >70 yo

Front 80

What are the red flags for when to suspect an infection?

Back 80

- Constitutional symtoms (e.g. fever, chills)
- Recent bacterial infection (e.g. urinary tract or skin infections, pneumonia)
- Immunosuppression
- Intravenous drug abuse

Front 81

28 y male presents w/ right sided low back pain 3 days ago while putting toddler into car seat; no radiation of pain, numbness, tingling, weakness; tender and hypertonic lumbar paraspinals, limited lumbar ROM, normal neuro.

What is it / what should you do?

Back 81

Lumbar Strain:
- No imaging necessary
- Recommend relative rest <48 hrs
- NSAIDs
- Muscle relaxant
- Physical therapy if >4 wks or recurring
- Should be self-limited

Front 82

Lumbar Strain:
- History
- Etiology
- Exam
- Treatment

Back 82

- History – axial low back pain after acute injury, such as lifting or twisting
- Etiology – muscle disruption from excessive stretch or tension
- Exam – localized muscle tenderness, reduced ROM
- Treatment – no imaging, relative rest, NSAIDs, muscle relaxant, physical therapy if >4 wks

Front 83

37 y painter w/ 2 weeks of progressive pain in neck and right scapular pain and arm; > 1 week of shooting pain and numbness down arm to hand; numbness in arm into hand and arms feel weak; positive Spurling (extension of neck), weak elbow extension, decreased pain over middle finger.

What reflex would you expect to be abnormal?

Back 83

Absent triceps reflex

Front 84

37 y painter w/ 2 weeks of progressive pain in neck and right scapular pain and arm; > 1 week of shooting pain and numbness down arm to hand; numbness in arm into hand and arms feel weak; positive Spurling (extension of neck), weak elbow extension, decreased pain over middle finger.

What is it / what should you do?

Back 84

- Radiculopathy (probably disc herniation)
- Imaging: MRI, possible EMG
- Relative rest, Physical therapy
- Surgical discectomy if progressive/severe weakness or unresponsive to conservative care
- Pain: NSAIDs, oral or epidural corticosteroids, limited opioids, neuromodulators

Front 85

Radiculopathy:
- History
- Etiology
- Exam
- Treatment

Back 85

- History – pain and possible numbness/weakness in limb > axial spine (lumbar: worse sitting/flexion, better standing/extension)
- Etiology – disc herniation most common
- Exam – SLR or Spurling positive, neurologic deficits (myotomal weakness, decreased reflex, dermatomal reduced sensation)
- Treatment – Imaging: MRI, possible EMG. Relative rest, physical therapy, surgical discectomy if progressive/ severe weakness or unresponsive to conservative care. For pain, NSAIDs, oral or epidural corticosteroids, limited opioids, neuromodulators

Front 86

What are the most comfortable positions for someone with a lumbar disc herniation?

Back 86

- Laying down
- Standing up straight better than sitting up straight

Front 87

34 y male presents with chronic back stiffness and pain that has been getting worse for the past few years, stiffness is worse in morning and loosens up somewhat by mid-day, but he has difficulty getting up from chair after prolonged sitting; he feels better when he exercises. Decreased back ROM w/o neurological defects.

What is it / what should you do?

Back 87

Ankylosing Spondylitis (inflammatory spondyloarthropathy)
- Plain x-rays - earliest finding is sacroiliitis
- Labs: HLA-B27, C-reactive protein, Sed rate
- Meds: NSAIDs typically marked relief, Anti-TNF agents
- PT - emphasis on spine extension

Front 88

Ankylosing Spondylitis:
- History
- Etiology
- Exam
- Treatment

Back 88

- History – onset of low back pain < age 40, insidious, better with exercise, pain at
night and on waking, not improved with rest
- Etiology – inflammatory spondyloarthropathy, usually sacroiliitis initially. Can be associated with uveitis, inflammatory bowel disease, psoriasis among other features
- Exam – Reduced lumbar ROM, often tender to palpation over sacroiliac joints with positive joint provocative tests (FABER, Gaenslen).
- Treatment – Imaging: plain x-rays – earliest finding sacroiliitis. Later syndesmophytes can progress to “bamboo spine”.
Labs: HLAB27, C-reactive protein, sed rate.
NSAIDs – typically marked relief. Consider anti-TNF agents.
Physical therapy, emphasis on spine extension

Front 89

What are the early signs of Ankylosing Spondylitis?

Back 89

- Widening of SI joints w/ adjacent sclerosis compatible w/ sacroiliitis
- Posterior longitudinal ligament sclerosis at L1-L2, L2-L3

Front 90

What are the late signs of Ankylosing Spondylitis?

Back 90

- Fusion of both SI joints, compatible w/ advanced sacroiliitis
- Symmetric syndesmophytes bridging all all vertebral bodies resulting in "bamboo spine"
- Ossification of anterior, posterior, and interspinous longitudinal ligaments

Front 91

59 y female w/ low back ache for several months, limits standing and walking. No injury or trauma. No pain sitting. Central, low midline lumbar pain. No LE referral, numbness, tingling, or weakness.

What is it / what should you do?

Back 91

Facet joint arthropathy / Osteoarthritis
- Imaging: none or plain lumbar x-rays.
- Meds: NSAIDs, mild analgesics.
- Physical therapy (flexion bias)
- Possibly facet joint injections

Front 92

Osteoarthritis (facet joints):
- History
- Etiology
- Exam
- Treatment

Back 92

- History – axial low back pain, gradual onset (cervical: worse with cervical extension; lumbar: worse standing/walking, better sitting/lying)
- Etiology – gradual degenerative changes/osteoarthritis to zygoapophyseal (facet) joints; more common age > 55
- Exam – nonspecific, pain provoked with active extension, relieved with flexion
- Treatment – Imaging: none or plain lumbar x-rays. NSAIDs, mild analgesics.
Physical therapy (flexion bias), possibly facet joint injections

Front 93

77 y male w/ 1 year of intermittent low back pain, w/ pain down both legs to ankles when walking >1/4 mile. Pain resolves w/ sitting and no pain in bed. No numbness, tingling, or weakness. Reduced lumbar ROM (pain-free) and mildly decreased Achilles reflex bilaterally).

What is it / what should you do?

Back 93

Lumbar Stenosis (L3-L4)
- Imaging: MRI, possibly CT or EMG.
- Meds: NSAIDs, neuromodulators, epidural steroids
- Physical therapy (flexion bias), use of walker
- Surgery for lumbar decompression

Front 94

Lumbar Stenosis:
- History
- Etiology
- Exam
- Treatment

Back 94

- History – slowly progressive back and unilateral or bilateral leg pain (worse standing/walking, better sitting). Shopping cart sign – can walk much further if pushing cart (flexes spinal canal). Differentiate from vascular claudication (must sit or bend to relieve symptoms)
- Etiology – narrowing of the spinal canal (due to disc herniation/protrusion, ligamentum flavum thickening, osseous thickening of bone/facet joint, spondylolisthesis)
- Exam – nonspecific. Possibly flexed standing posture, reduced lumbar lordosis; otherwise unremarkable
- Treatment – Imaging: MRI, possibly CT or EMG. NSAIDs, neuromodulators, physical therapy (flexion bias), use of walker, epidural steroids, surgery for lumbar decompression

Front 95

65 y healthy female w/ 2 weeks of severe low back pain after playing vigorously w/ grandchildren. No leg pain or numbness/tingling. No red flags besides age. Exam w/ local tenderness in upper lumbar region, normal neuro exam.

What is it / what should you do?

Back 95

Osteoporosis / Compression Fracture
- Imaging: plain x-rays, possibly MRI or CT; DEXA scan to eval for osteoporosis.
- If malignancy considered: CBC, SPEP, alkaline phosphatase, sed rate.
- Meds: NSAIDs, acetaminophen, calcitonin, mild opioids.
- Consider bracing for 6 weeks. Physical therapy.
- Symptoms usually improve in 3 months.
- Vertebroplasty/kyphoplasty a consideration, evidence of efficacy limited.

Front 96

Compression Fracture
- History
- Etiology
- Exam
- Treatment

Back 96

- History – usually sudden thoracic or lumbar pain, often little to no trauma
- Etiology – majority related to osteoporosis, older patients; anterior vertebral body wedge fracture. T10, T11, T12, L1 most commonly. In younger patients w/o clear etiology, consider malignancy, multiple myeloma. 1/3 are asymptomatic
- Exam – tender over spinous processes, paraspinals. Worse: lumbar flexion. Better: lumbar extension. Normal neuro exam (unless nerve root affected).
- Treatment – Imaging: plain x-rays, possibly MRI or CT; DEXA scan to eval for osteoporosis. If malignancy considered: CBC, SPEP, alkaline phosphatase, sed rate. NSAIDs, acetaminophen, calcitonin, mild opioids. Consider bracing for 6 weeks. Physical therapy. Symptoms usually improve in 3 months. Vertebroplasty/kyphoplasty a consideration, evidence of efficacy limited.

Front 97

What are some underlying conditions that predispose to developing a compression fracture?

Back 97

- Osteoporosis (most common)
- Paget's disease (disorganized bone remodeling)
- Multiple Myeloma
- Breast Cancer
- Diabetes

Front 98

36 y executive chef w/ history of chronic low back pain. 1 week ago w/ increased pain and new right > left posterior thigh and calf pain after long flight. 4 days ago worsening back and leg pain, saddle anesthesia, which persists. 1 episode of bowel incontinence, difficulty emptying bladder, and leg weakness.

What is it / what should you do?

Back 98

Cauda Equina Syndrome
- Surgical emergency

Front 99

Cauda Equina Syndrome
- History
- Etiology
- Exam
- Treatment

Back 99

- History – leg pain, numbness, weakness; saddle anesthesia; bowel/bladder
dysfunction (urinary retention most common; urinary or stool incontinence)
- Etiology – large herniated disc compressing cauda equina most common (also epidural tumor, abscess, or hematoma)
- Exam – reduced or absent reflexes, weakness, decreased rectal tone
- Treatment – Surgical emergency

Front 100

74 yo w/ gradual progression of "walking funny". He notes 4 falls in past month d/t losing his balance, difficulty w/ buttoning his shirt and pants. Hyperreflexia at triceps, patellas, and Achilles, positive Hoffman's and Babinski, mild weakness of hand intrinsics and diffuse in legs, wide based gait w/ poor balance.

What is it / what should you do?

Back 100

Cervical Myelopathy
- Imaging: MRI.
- Surgical decompression (laminectomy) - may not correct neurological deficits, but will prevent progression
- No role for nonoperative treatment (unless not a surgical candidate)

Front 101

Cervical Myelopathy:
- History
- Etiology
- Exam
- Treatment

Back 101

- History – pain, numbness, weakness in arms and/or legs; balance and gait difficulties;
bowel/bladder dysfunction
- Etiology – cervical canal stenosis with spinal cord compression
- Exam – arm and/or leg weakness, upper motor neuron signs (hyperreflexia, Hoffman/Babinski, gait ataxia, increased tone)
- Treatment – Imaging: MRI. Surgical decompression. No role for nonoperative treatment.