Pathology cervical and thoracic spine lecture - tutor version (1) copy

A history of atherosclerotic vascular disease should be considered a red flag.

The diagnostic triangle consists of three key components: History, Examination, and Investigations. These elements work together to form a comprehensive assessment of a patient's condition.

Serious pathologies to consider include:

1. Cervical Fractures
2. Tumors
3. Infections (e.g., meningitis)
4. Vascular Issues (e.g., vertebral artery dissection)
5. Cauda Equina Syndrome

These conditions require immediate attention and intervention.

Red flags for neck pain include:

• Age: <20 or >55 years
• History of Trauma: Recent significant trauma
• Neurological Symptoms: Weakness, numbness, or bowel/bladder dysfunction
• Unexplained Weight Loss: Significant weight loss without trying
• Persistent Symptoms: Symptoms lasting longer than 6 weeks

These indicators suggest the need for further investigation.

Safety netting involves providing patients with clear guidance on what to do if their symptoms worsen or do not improve. This includes:

1. Follow-up Appointments: Scheduling follow-ups to monitor progress.
2. Emergency Signs: Educating patients on symptoms that require immediate medical attention.
3. Self-Management Strategies: Offering advice on managing symptoms at home.

This approach helps ensure patient safety and timely intervention if necessary.

Specific causes of neck pain include:

• Cervical Disc Herniation
• Cervical Spondylosis
• Whiplash Injury
• Radiculopathy
• Myelopathy

Understanding these causes aids in accurate diagnosis and treatment planning.

Specific neck pain is associated with identifiable pathologies (e.g., herniated discs, fractures), while non-specific neck pain does not have a clear underlying cause and is often related to muscle strain or poor posture.

• Specific Neck Pain: Identifiable cause, often requiring targeted treatment.
• Non-Specific Neck Pain: No identifiable cause, typically managed with conservative care.

Management strategies for neck pain include:

1. Physical Therapy: Exercises to improve strength and flexibility.
2. Medications: NSAIDs for pain relief.
3. Education: Informing patients about their condition and self-management.
4. Surgery: Considered in severe cases with neurological deficits.

Evidence supports a multimodal approach tailored to individual patient needs.

Non-specific low back pain (NSLBP) accounts for over 90% of all low back pain cases.

The three categories of low back pain are:

1. Serious/Specific pathology: <1%
2. Radicular pathology: 5-10%
3. Non-specific low back pain: >90%

It is important to screen for specific pathologies in approximately 10% of patients and serious pathologies in about 1% of patients to ensure proper diagnosis and treatment.

The serious pathologies of the spine include:

1. Neoplasm
2. Spinal Infection
3. Vertebral Fracture (traumatic or nontraumatic)
4. Inflammatory causes
5. Vertebral Basilar Insufficiency
6. Cervical Myelopathy
7. Cauda Equina Syndrome

• Current or previous history of cancer
• Family history (1st degree relative)

Unexplained weight loss – the specific amount of weight lost should be assessed.

• Prolonged use of steroids
• Intravenous drug use

This type of pain is considered non-mechanical and may suggest a serious underlying condition.

• Fever or feeling systemically unwell
• Urinary tract infection

• Fall from a height or motor vehicle accident in young patients
• Minor fall or heavy lifting in older patients or those with possible osteoporosis

Bladder or bowel incontinence is a significant red flag that may indicate serious underlying pathology.

Urinary retention with overflow incontinence is a red flag that may indicate a serious condition requiring further evaluation.

• Patients under 20 years with back pain are significant
• Back pain in patients over 80 years old is also a red flag

• Bilateral paraesthesia
• Multilevel neurological symptoms
• Hand intrinsic muscle wasting
• Clumsiness or decrease in fine motor coordination

This could indicate a serious underlying condition and should be considered a red flag.

• Rheumatoid Arthritis (RA)
• Down syndrome
• The 5 D’s (Dizziness, Diplopia, Dysphagia, Dysarthria, Drop attacks)
• The 3 N’s (Nausea, Nystagmus, Numbness)
• Ataxia

The red flags include:

1. Saddle anaesthesia
2. Loss of anal sphincter tone
3. Major motor weakness in lower extremities
4. Fever
5. Vertebral tenderness
6. Limited spinal range of motion in the cervical spine
7. Neurological findings persisting for more than one month
8. Palpable pulsatile abdominal mass (possible abdominal aortic aneurysm)

• History of 'cancer' (common primary sources: breast, bronchus, thyroid, kidney, prostate, rarely bowel)
• Unexplained weight loss
• Age >50 years & <20 years
• Night pain that disturbs sleep / night sweats
• No improvement in symptoms in a 4-6 week period
• Pain at rest

Unexplained weight loss often indicates advanced disease progression, as it typically occurs when the body is unable to maintain weight due to cancer's metabolic demands or effects on appetite.

• Refer to GP
• Consider blood tests
• Imaging studies
• Utilize the 2-week wait pathway for urgent cases

Night sweats can indicate various conditions, including neoplasms, but they may also be related to other factors such as menopause. It's important to assess the overall clinical picture.

Possible infection red flags include:

• Immunocompromised state (e.g., history of systemic steroid use, organ transplant, HIV, diabetes mellitus)
• History of Tuberculosis (TB)
• History of intravenous drug abuse
• History of cervical/thoracic surgery within the last 12 months
• Persistent fever or feeling systemically unwell
• Recent bacterial infection (e.g., pyelonephritis, cellulitis, pneumonia)

Identifying infection red flags is crucial because they may indicate serious underlying conditions that require immediate attention. They can show potential routes of infection, the patient's overall health status, and the need for further testing or referral to ensure comprehensive care beyond just musculoskeletal issues.

In an MSK setting, clinicians should:

1. Conduct a thorough patient history to identify any red flags.
2. Perform a respiratory assessment to check for signs of infection.
3. Check the patient's temperature to identify fever.
4. Evaluate other systems beyond the musculoskeletal system to ensure a holistic approach to patient care.

Referral pathways for patients with infection red flags may include:

• Urgent referral to a General Practitioner (GP) for further evaluation.
• Referral to Accident & Emergency (A&E) if the patient shows severe symptoms or requires immediate care. Rationalizing these pathways helps ensure timely intervention and management of potential infections.

Referred pain is pain that is felt in a location other than where the initial injury occurred. In spinal stenosis, this can manifest as pain radiating to areas such as the arms or hands, despite the source being in the spine.

The red flags include:

• Urinary incontinence (loss of sensation passing urine)
• Urinary retention (loss of sensation of bladder fullness)
• Saddle anaesthesia
• Faecal incontinence
• Decreased anal sphincter tone
• Bilateral lower extremity weakness or numbness
• Progressive neurological deficit (major motor weakness, major sensory deficit)

Possible symptoms include:

• Urinary incontinence
• Urinary retention
• Saddle anaesthesia
• Faecal incontinence
• Decreased anal sphincter tone
• Erectile dysfunction
• Bilateral lower extremity weakness or numbness
• Progressive neurological deficit
• Major motor weakness (e.g., knee extension, ankle eversion, foot dorsiflexion)
• Major sensory deficit
• Gait disturbance

The cauda equina is a bundle of spinal nerves and nerve roots that:

• Consists of the second through fifth lumbar nerve pairs, first through fifth sacral nerve pairs, and the coccygeal nerve.
• Arises from the lumbar enlargement and the conus medullaris of the spinal cord.
• Occupies the lumbar cistern, a subarachnoid space inferior to the conus medullaris.
• Innervates pelvic organs and lower limbs, providing motor innervation to the hips, knees, ankles, and feet, as well as sensory innervation to the perineum.

Signs of sudden-onset cauda equina syndrome include:

• Bilateral radicular leg pain or unilateral pain progressing to bilateral pain
• Severe or progressive neurological deficit (e.g., major motor weakness)
• Difficulty initiating micturition or impaired sensation of urinary flow
• Loss of sensation of rectal fullness
• Erectile dysfunction or sexual dysfunction
• Perianal or perineal sensory loss (saddle anaesthesia)
• Unexpected laxity of the anal sphincter
• Gait disturbance or difficulty walking

Key symptoms include:

• Acute onset disturbance with no single inciting or remediating circumstance.
• Bilateral leg pain.
• Negative physiological reflexes.
• New CES subjective symptoms such as:
  • Saddle or genital altered sensation.
  • Bladder changes (difficulty initiating micturition or incomplete bladder emptying).
  • Altered sensation in the perineal or genital area.
  • Weakness or progressive neurological deficit in both legs.
  • New onset bladder or bowel dysfunction.

When a patient presents with sudden onset saddle, cauda, or leg pain, it raises suspicion for Cauda Equina Syndrome (CES). It is important to:

• Rule out CES as a potential diagnosis.
• Be cautious of over-treatment in cases of unilateral radicular leg pain that progresses to bilateral symptoms.
• Consult a specialist urgently if CES or SCIWORA symptoms are suspected.
• Discuss symptoms in detail, especially pain and sensation in the bum area, and consider a digital rectal examination if perineal sensation is suspected.

Warning signs for Cauda Equina Syndrome (CES) include:

• Saddle or genital altered sensation.
• Bladder changes such as difficulty initiating micturition or incomplete bladder emptying.
• Altered sensation in the perineal or genital area.
• Weakness or progressive neurological deficit in both legs.
• New onset bladder or bowel dysfunction or difficulty with sexual dysfunction.

Cauda Equina Syndrome affects 1-3 people per 100,000 population in England, with around 8,000 suspected cases every year.

If not assessed and treated urgently, Cauda Equina Syndrome can lead to lower limb paralysis and loss of bowel, bladder, and sexual function.

The pathway is designed to support clinical teams in diagnosing and treating suspected Cauda Equina Syndrome without delay, improving patient outcomes.

Documentation should include signs, symptoms, duration, frequency, progression, time & date of assessments, time of referral, person receiving referral, and recommended advice received.

Staying abreast of the latest guidance is crucial for being an evidence-based practitioner and ensuring timely diagnosis and treatment of this serious condition.

Safety netting is a management strategy used for individuals who may present with possible serious pathology. It involves providing advice on:

• Signs and symptoms to look out for
• Actions to take if these signs or symptoms occur
• The time frame within which action should be taken

Many patients experience a combination of back pain, leg pain, leg numbness, and weakness. These symptoms can be distressing but do not always indicate a need for emergency care.

The warning signs include:

1. Loss of feelings and/or weakness in your legs or genitals
2. Numbness/altered feeling when using toilet paper to wipe yourself
3. Increasing difficulty starting or controlling your bladder
4. Loss of sensation when passing urine
5. Unawareness of bladder fullness or emptiness
6. Loss of sensation when passing a bowel motion
7. Loss of sensation in genitals during sexual intercourse

Any combination of these symptoms requires immediate help.

The main groups of specific causes of neck pain include:

• Age 65 years or older
• Dangerous mechanism of injury (e.g., fall from a height of 1m or more, axial load to the head)
• Paraesthesia in upper or lower limbs

• Involved in a minor rear-end motor vehicle collision
• Comfortable in a sitting position
• Ambulatory at any time since the injury
• No midline cervical spine tenderness
• Delayed onset of neck pain

Unable to actively rotate their neck 45 degrees to the left and right, but only assessed if there are no high-risk factors present.

Having none of the low-risk factors and being able to actively rotate their neck 45 degrees to the left and right.

The Canadian C-Spine Rule is a decision-making tool used to determine when radiography should be utilized in patients following trauma, specifically to assess the need for imaging in cases of potential cervical spine injury.

The CCR is applicable to patients who are alert (Glasgow Coma Scale score of 15) and stable following trauma where cervical spine injury is a concern.

The CCR is not applicable in non-trauma cases, if the patient has unstable vital signs, acute paralysis, known vertebral disease, previous history of cervical spine surgery, or if the patient is under 16 years of age.

A Negative Likelihood Ratio of less than 5% indicates that there is only a 5% chance that if a negative finding is obtained from the CCR, the patient would still have a cervical spine injury.

• Dizziness
• Diplopia, blurred vision or transient hemianopia
• Drop attacks (loss of power or consciousness)
• Dysphagia (problems swallowing)
• Dysarthria (problems speaking)

• Nystagmus
• Nausea or vomiting
• Neurological symptoms: Numbness, Ataxia

The history of atherosclerotic vascular disease and risk factors including:

• Smoking
• Hypertension
• Age
• Gender
• Family history and genetics
• Hyperlipidemia

Inadequate blood flow through the posterior circulation of the brain.

Cervical radiculopathy is characterized by nerve root irritation affecting conduction along the nerve, often involving dermatome and/or myotome. It can occur with or without radicular pain, and its causes may include disc issues, spondylosis, or spondylolisthesis. Clinically, it can be challenging to diagnose definitively.

Radicular pain occurs when nerve tissue is irritated, often associated with cervical radiculopathy, while referred pain is the central nervous system's failure to accurately locate the source of pain, leading to pain felt in areas other than the actual site of injury.

The most common type of myelopathy is Degenerative Cervical Myelopathy (DCM), which primarily affects individuals aged 50 or older.

Yes, cervical myelopathy can also occur in younger people.

Cervical myelopathy is more common than thoracic myelopathy.

Potential causes of cervical myelopathy include:

1. Large disc herniation
2. Fractures
3. Metastatic disease (mets)
4. Other degenerative changes

Key aspects to assess include:

1. Paraesthesia: Determine if it is unilateral or bilateral.
2. Neck Pain/Stiffness: Assess the presence and severity.
3. Arm/Leg Pain: Identify if it is unilateral or bilateral.
4. Clumsiness/Dexterity Issues: Inquire about problems with tasks like buttoning, texting, or applying mascara.
5. Weakness: Look for signs of reduced grip strength, dropping objects, heavy legs, or tripping.
6. Balance: Ask about any recent or significant changes in balance.
7. Mobility: Check for any recent or significant changes in walking.
8. Bladder/Bowel/Saddle Symptoms: Assess for any issues in these areas.

Hyper-reflexia is the most sensitive test for assessing upper and lower limb sensation, power, and reflexes.

Upper motor neuron tests include Clonus, Hoffmans, Babinski, Rombergs, and Tandem tests.

A neurological exam is often normal in the early stages; do not be reassured by negative tests if there is a clear subjective history. It's important to listen, believe, and have a low threshold for onward referral.

During a neurological examination, check gait for any signs of poor balance or ataxia.

Common symptoms include:

• Neck pain/stiffness with possible radiation to arms and/or legs
• Altered sensation and/or weakness in arms and/or legs
• Loss of control for fine movements of the hands (e.g., difficulty doing up buttons or picking up coins)
• Imbalance or unsteadiness while walking
• Changes in bladder/bowel function or sexual dysfunction

The progression of cervical myelopathy is usually slower compared to cauda equina syndrome. This difference is related to the anatomy and physiology of the spinal cord versus the cauda equina, as cervical myelopathy involves spinal cord dysfunction due to compression in the neck.

Patients with symptoms of cervical myelopathy should be referred onwards to a General Practitioner (GP) depending on the specific signs and symptoms (S&S) presented.

Whiplash-associated disorder (WAD) refers to injuries sustained due to sudden acceleration-deceleration movements, commonly associated with motor vehicle accidents.

The Quebec classification for Whiplash-associated disorders includes:

Common symptoms of Whiplash-associated disorder include:

• Neck pain that may refer to the shoulder or arm
• Headache
• Reduced range of neck movements
• Muscular spasm
• Stiffness
• Deafness
• Tinnitus
• Dysphagia and nausea

Common symptoms include:

• Dizziness
• Paraesthesiae (tingling sensations)
• Memory loss
• Temporomandibular joint pain
• Visual disturbances

Chronic Whiplash Associated Disorder (WAD) is characterized by a variety of symptoms that persist for more than 6 months after an acute WAD. These symptoms may include:

• Neck pain & stiffness
• Persistent headaches
• Dizziness
• Upper limb paraesthesia
• Psychological & emotional symptoms

Before examining movements, exclude:

1. Features of a serious head/neck injury
2. Risk factors for a serious injury using the Canadian C spine Rule to identify risk for cervical fracture and decide if imaging is needed.

If a serious cervical injury or head injury is suspected, an urgent referral to A&E is required.

The key components include:

1. Self-care advice: Educating the patient on managing symptoms at home.
2. Analgesia: Providing pain relief through medications.
3. Physiotherapy: Engaging in physical therapy to improve mobility and strength.
4. Early treatment of psychological factors: Addressing any psychological issues that may arise early in the treatment process.

Torticollis is characterized by a twisted neck resulting in same side lateral flexion and contralateral rotation.

The key component of the assessment for torticollis is to exclude 'red flags' that may indicate more serious underlying conditions.

Management strategies for torticollis include:

1. Reassurance - symptoms usually resolve within 24-48 hours.
2. Pain relief - Paracetamol or ibuprofen; codeine if required.
3. Gentle exercise and intermittent heat/cold application.
4. Posture and pillow advice.
5. Avoidance of cervical soft collar and advice on driving.

• Reassure the patient that neck pain is normal.
• Encourage activity and a return to work/lifestyle as soon as possible.
• Advise against using a collar.
• Provide analgesia as needed.

In addition to the acute management:

• Refer to physiotherapy.
• Implement stretching and strengthening exercises.
• Address psychosocial factors.
• Involve occupational health if required.

In addition to the previous recommendations:

• Refer to physiotherapy.
• Continue stretching and strengthening exercises.
• Address psychosocial factors.
• Involve occupational health if required.
• Conduct a biopsychosocial factors assessment and management.
• Ensure multidisciplinary team (MDT) involvement.

• Protrusion: The disc bulges out but remains contained within the annulus fibrosus.
• Extrusion: The disc material breaks through the annulus fibrosus and protrudes outwards.
• Sequestration: The disc material separates from the main disc and can migrate away from the original site.
• These conditions may lead to radiating pain, altered sensation, or weakness in the arm, and symptoms may worsen with coughing or sneezing.

• Trauma: Sudden injury can lead to disc herniation.
• Unaccustomed activity: Engaging in new or intense physical activities can stress the disc.
• Torsion: Twisting movements can cause disc issues.
• Asymptomatic situations: Many individuals may have a prolapsed disc without any noticeable symptoms.

• Estimates suggest that approximately 66-80% of disc prolapses may reabsorb over time.
• Most patients experience a reduction or removal of clinical signs and symptoms within a few weeks to several months.

• Imaging does not always correlate with clinical signs and symptoms; it is essential to consider the whole clinical picture when assessing disc herniation.

Spinal stenosis is the narrowing of the spinal canal, leading to diminished space for neural and vascular structures. Primary symptoms include radiating pain, altered sensation, and weakness in the arm or hand. Symptoms may worsen with walking or extension and improve with flexion or rest.

Spinal stenosis is typically identified using MRI. Management is usually conservative, unless symptoms are severe or the patient cannot cope, in which case surgery may be considered.

Spondylosis is commonly associated with:

• Spinal stenosis: Narrowing of the spinal canal that can lead to nerve compression.
• Degenerative spondylolisthesis: Forward slippage of a vertebra due to degeneration.
• Osteoarthritis (OA): Degenerative joint disease that can affect the facet joints of the spine.

These associations can lead to symptoms such as stiffness, reduced range of motion (ROM), and pain.

Individuals with spondylosis may experience:

• Stiffness and decreased range of motion (ROM)
• Generalized stiffness and pain
• Radiating pain into the arm or hand, possibly accompanied by altered sensation or weakness

These symptoms can vary in intensity and may not always correlate with MRI findings.

Spondylosis can contribute to spinal stenosis through:

• Formation of osteophytes: Bone spurs that can narrow the spinal canal.
• Thickening of ligaments: Such as the ligamentum flavum, which can further reduce space for the spinal cord and nerves.

These changes can lead to increased pressure on neural structures, resulting in symptoms of spinal stenosis.