Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

S2Secrets Hesham Ahmed Case14 Ahmedh17@cardiff.ac.uk Rayan CherifContents Anatomy Physiology Spinal pathologyContents Anatomy SBA Howmanyunfusedvertebralsegmentsarethereinthehumanspine A 24 B 25 C 28 D 33 SBA SBAquestion:jgvvjx,e,jd Xjgsv,jgve egfvh3gecdh,: A 24 B C Danatomy Spinalanatomy — 7, 12, 5 – unfused — Sacrum – 5 fused vertebrae — Coccyx – 4 fused vertebrae — Cervical Lordosis Image — Thoracic Kyphosis — Lumbar Lordosis — Weight bearing — Anterior arch – 80% load + compression — Posterior arch – 20% load + tensionanatomy Spinalanatomy Vertebrae components: • Anterior Body • Posterior Arch Vertebral Arch components: • Vertebral foramen • Lamina – x2 • Pedicle – x2 m a • Spinous process e • Articular process • Transverse process Intervertebral disc: • Central Nucleus Pulposus • External Annulus Fibrosus SBA WhichvertebraedoesRib5articulatewith? A T3-T4 B T4-T5 C T5-T6 D T4 SBA WhichvertebraedoesRib5articulatewith? A B C T5-T6 D Spinalanatomy Cervical spine Thoracic spine Lumbar spine – 8 nerves – Flat on left side – Aorta – Large kidney shaped vertebral – C3-C6 (typical) – Ribs 2-10 articulate with rostral body – Bifid spinous process + foramen neighbour – L1-4 – typical vertebra transversarium – Ribs 1, 11, 12 articulate with – Flexion + extension + lateral – C2 dens (odontoid peg) – head named vertebra bend movements – Thoracolumbar junction – T9- – C1-C6 transverse foramen – 12 vertebral Artery – Limited movement – breathing – C7 transverse foramen – vertebral – negative intrathoracic Vein + fat pressure – Uncinate process limits lateral flexion SBA A radiologist is performing cervical lymph node biopsy in the posterior important structure passes through which is commonly mistaken for a as an lymph node. Which structure is the radiologist referring to? A Accessory nerve B External jugular vein C Common carotid artery D Internal jugular vein SBA A radiologist is performing cervical lymph node biopsy in the posterior triangle. She tells you that she must be extra careful in this area as an lymph node. Which structure is the radiologist referring to?n for a A Accessory nerve B C DNeckanatomy Text SBA What is the most superficial covering muscle of the back A Rhomboid major B Rhomboid minor C Splenius capitis D Trapezius SBA A radiologist is performing cervical lymph node biopsy in the posterior triangle. She tells you that she must be extra careful in this area as an lymph node. Which structure is the radiologist referring to?n for a A B C D TrapeziusBackanatomy TextContents Physiology SBA 23-year-old man comes into the ED with a fracture. On examination the patient seems to have fractured one of his bones which is majorly trabecular. Which bone is he most likely to have fractured? A Femur B Humerus C Radius D T5 SBA 23-year-old man comes into the ED with a fracture. On examination majorly trabecular. Which bone is he most likely to have fractured? A B C D T5 Bonestructure Types of bone: Cortical – more dense, less metabolically active image Trabecular – less dense, more metabolically active Bonemetabolism Hypocalcaemia: PTH secreted Hypercalcaemia : Acts on: Calcitonin secreted – osteoclast inhibition • Kidney Hypocalcaemia side • Bone Hypercalcaemia side effects: effects: • ↓ Nervous • Tetany Kidney: system functions • Cramps • PTH stimulates hydrogenation of • Bone pain • Paraesthesia inactive vitamin D to form active • Renal calculus • Seizures Vitamin D • ↑ reabsorption of Ca2+ • Blood vessel calcification • ↑ excretion of PO4- • Diffuse abdominal pain Bone: • Depression • Osteoclast stimulation SBA 65-year-old woman with a history of stage 4 kidney failure is admitted into What is the cause of her abnormal blood results?ts show the following: A Hb – 115 Tertiary hyperparathyroidism WBC – 7.0 Na+ - 127 K+ - 4.5 B Ca2+ - 2.8 Secondary hyperparathyroidism PTH – 78 (14-65) ALP – 142 (30-100) C Primary hyperparathyroidism D Pituitary adenoma SBA hospital with concerning symptoms. Her blood tests show the following: into What is the cause of her abnormal blood results? A Tertiary hyperparathyroidism B WBC – 7.0 Na+ - 127 C K+ - 4.5 Ca2+ - 2.8 ↑ PTH – 78 (14-65) PO4- - ↓ D ALP – 142 (30-100) Parathyroiddisorders Hypoparathyroidism Hyperparathyroidism Thyroid surgery Solitary adenoma ↓PTH ↑Ca2+ ↓ Ca2+ ↓ PO4- ↑ PO4- ↑ PTH (or normal) Tetany Pepper pot skull Trousseau’s sign Bone pain Polydipsia/uria Chvostek’s sign Prolonged QT interval Renal stones Alfacalcidol Constipation Depression Parathyroidectomy / Cinacalcet SBA A 78-year-old woman comes into the ED after being found on the floor by her carer. On examination, she seems to have suffered from a neck of femur next step in management?n the morning and is rushed into surgery. What is the A Assess her PTH levels B Diagnose with osteoporosis with no further tests C Perform DEXA scan D Safety net and discharge home under GP care SBA 65-year-old woman with a history of stage 4 kidney failure is admitted into What is the cause of her abnormal blood results?ts show the following: A B Diagnose with osteoporosis with no further tests C D Osteoporosis Pathophysiology: Diagnosis : – ↑ Inflammatory cytokines leading to osteoclast up regulation and osteoblast – DEXA scan – T & Z scores depression – T score – elderly, bone mass compared to younger reference – ↑ bone resorption (especially in Risk factors: – Z score – young, adjusted for metabolically active trabecular bone – Age age, sex and ethnicity found in spine and hips) – ↓ Bone density – Gender – T score > -1 → normal – Easily susceptible to fractures – BMI – T score -1 to -2.5 → osteopenia – Smoking – T score < -2.5 → osteoporosis – Endocrine – Glucocorticoid use Management: st – Alcohol Bisphosphonates – 1 line – – RA alendronate – CKD Teriparatide – 7 line – PTH recombinant SBA A toddler is brought by their parents to see a paediatrician. On examination the child has brittle bones and seems to be in a lot of pain. The paediatrician performs a plain radiograph of their lower limbs which confirms the diagnosis. Given the most likely diagnosis, what is seen on this patient’s plain radiograph? A Stress fracture B Tendon calcification C Valgus deformity D Varus deformity SBA A toddler is brought by their parents to see a paediatrician. On examination the child has brittle bones and seems to be in a lot of limbs which confirms the diagnosis. Given the most likelyeir lower diagnosis, what is seen on this patient’s plain radiograph? A B C D Varus deformity Osteomalacia Pathophysiology: – ↓ Vit D levels – malabsorption, diet, sun light Symptoms: – ↓ Ca2+ – Bone pain – ↓ PO4- – Bone / muscle tenderness – ↑↑↑ ALP – Fractures – New bone is not mineralised as such – susceptible to fractures Paget’sdiseaseofthebone Symptoms : Pathophysiology: – Bone pain – MSK deformities – Pathological osteoclast activity – – Enlarged skull bone resorption – Heart failure – Compensated uncontrolled osteoblast activity Investigations: – Formation of disorganised bone – – Isolated raised ALP weaker, less compact and more – ↑ Urinary hydroxyproline susceptible to fracture – ↑ uptake on bone scintigraphy – Emulates cancer progression – may lead to sarcoma Management: – Skull – spine – pelvis – long bones of – Bisphosphonates – oral risedronate lower limb / IV zolendronate – Symptomatic only (bone pain – deformity – fracture) SBA Which modality is typically the last to be blocked when using a local anaesthetic? A Dull pain B Light touch C Heat D Motor SBA Which modality is typically the last to be blocked when using a local anaesthetic? A B C D Motor Commonlyusedpreparations Lidocaine Bupivacaine • Slower onset of action • Fast onset of action • Short duration of action • Longer duration of action Maximum doses: Maximum doses: • Without adrenaline: 3 mg/kg • Without adrenaline: 2 mg/kg • With adrenaline: 7 mg/kg • With adrenaline: 2 mg/kg Neuromusculardrugs Depolarising Non-depolarising One type in clinical use Many types in clinical use (Suxamethonium) (Atracurium, Mivacurium, vecuronium etc.) Competitive agonist Competitive antagonist Slowly broken down Not broken down Fasciculations No Fasciculations Works in 60 seconds; lasts 10 Works in 2 to 3 minutes, lasts 20- minutes 30 minutes SBA A 31-year-old pro BMX rider presents to A&E with an open humeral shaft fracture after a traumatic fall. He was managed with an open reduction internal fixation. 3 months later he is seen by a neurologist as the sensation to his hand What is the most likely mechanism of injury?he also cannot extend his wrist. A Radial Nerve neurapraxia B Radial nerve neurotmesis C Ulnar nerve neurapraxia D Ulnar nerve neurotmesis SBA fracture after a traumatic fall. He was managed with an open reduction internal fixation. 3 months later he is seen by a neurologist as the sensation to his hand has still not returned since the injury and he also cannot extend What is the most likely mechanism of injury? A B Radial nerve neurotmesis C D Nerveinjury • Neurapraxia – Myelin damage, It is a • 1 degree - Seddon's neurapraxia and first-degree are the temporary interruption of conduction Neurapraxia same. without loss of axonal continuity. ND • Slowed conduction • are the same.Seddon's axonotmesis and second-degree • Axonotmesis – Loss of axonal continuity • Only the axon is disrupted, with endoneurium intact. and its covering of myelin, but • 3 degree- included within Seddon's axonotmesis preservation of the connective tissue • lesion of the endoneurium, but the epineurium and framework of the nerve Axonotmesis perineurium remain intact. • Recovery is possible, but surgical intervention may be • No conduction required. • Neurotmesis – Total severance or th disruption of the entire nerve fibre. This • 4 degree- included within Seddon's axonotmesis • Only the epineurium remain intact. includes transection of the axon, endo-, • In this case, surgical repair is required. peri-, and epineurium. • 5 degree- Included within Seddon's neurotmesis. • May be partial or complete. Neurotmesis • Complete transection of the nerve, including the • No conduction epineurium. • Recovery is not possible without an appropriate surgical treatment. WallerianDegeneration Release Axon and myelin Nerve injury Ca2+ influx of proteases by breakdown Schwann cells Macrophages Macrophages are Nissl reaction Nucleus migrates to clear cellular debris recruited by the (chromatolysis) periphery Schwann cells Schwann cells supply End result – macrophages with shrunken nerve cell debris to engulf skeleton and removeNerveregeneration Text Nerveregeneration • Neurotrophicfactors stimulate and guide the nerve to grow towardsits target • Growth cone contains filopodia → extend image towardsthe distal stump • Basal lamina of Schwann cells + NGF attract the filopodia • Thrombus and type I collagen repel growth cones and inhibit axonal elongationContents Spinal pathology SBA You are volunteering with mountain rescue and find a woman lying on the floor. On examination she has a blood pressure of 92/50, a temperature of 36C, Heart rate: 47bpm, SPO2: 96% and scores a V on the AVPU scale. Which of the following signs indicates the woman likely has a spinal cord injury? A Heart Rate B Level of consciousness C Oxygen Saturation D Temperature SBA You are volunteering with mountain rescue and find a woman lying on the 36C, Heart rate: 47bpm, SPO2: 96% and scores a V on the AVPU scale.ure of Which of the following signs indicates the woman likely has a spinal cord injury? A Heart Rate B C D SBA Anna was taken to hospital and found to have lack of sensation flaccid paralysis and absent reflexes below the level of T5. You suspect this is due the following reflexes can you test to determine if the spinal shock isf beginning to resolve? A Achilles tendon B Bulbocavernosus reflex C Brachioradialis reflex D Plantar reflex SBA Anna was taken to hospital and found to have lack of sensation flaccid paralysis and absent reflexes below the level of T5. You suspect this is due to spinal shock which you know will resolve starting caudally. Which of the to resolve?eflexes can you test to determine if the spinal shock is beginning A B Bulbocavernosus reflex C D Spinaland Neurogenic shock Spinal Shock Neurogenic Shock Loss of spinal cord function caudal to 1. After cord transection – T1-L2 the level of the injury 2. Interrupted sympathetic outflow SSx: 3. Results in either decreased • flaccid paralysis sympathetic tone or increased • Anesthesia parasympathetic tone • absent bowel and bladder 4. Results in decrease in control peripheral vascular resistance • Areflexia due to vasodilation. 5. results in decreased preload and Resolves within 24hrs – reflex arcs thus decreased cardiac output caudal to the injury return – BCR Sx: Bradycardia, Hypotension Resolution allows identification of HYPOTENSION TO BE TREATED AS complete spinal cord injury HAEMORRHAGIC SHOCK UNTIL PROVEN OTHERWISE SBA A 32-year-old man with a spinal cord injury is having his catheter changed on the ward. He starts feeling unwell during the procedure and his blood pressure increases to 201/123 face and neck. This settles once the new catheter has been placed and his blood pressure returns to normal. At which spinal cord level has the patient most likely?been injured A C7 B T10 C T12 D L3 SBA A 32-year-old man with a spinal cord injury is having his catheter changed on the ward. He mmHg, but his heart rate remains at 65 bpm, and he becomes flushed and sweaty in his23 face and neck. This settles once the new catheter has been placed and his blood pressure returns to normal. At which spinal cord level has the patient most likely been injure? A C7 B C DAutonomicdysreflexia SBA Grogu, a 67-year-old male, presents with a 2 months history of back pain, night sweats, headaches and unintentional weight loss. The registrar on call performs a set of imaging and blood tests to determine the diagnosis. tumour is he most likely suffering from?pinal column tumour. What A Astrocytoma B Neurofibroma C Osteoblastoma D Schwannoma SBA Grogu, a 67-year-old male, presents with a 2 months history of back pain, night sweats, headaches and unintentional weight loss. The registrar on The patient is found to have a primary spinal column tumour. Whatiagnosis. tumour is he most likely suffering from? A B C Osteoblastoma DContent-wouldbegoodforadiagram? SBA Erwin, a 45-year-old males comes into the GP surgery complaining of back pain. This has been going on for a while and is troubling him in his work as an army general. He denies any weight loss or night sweats. He has a past presentation is regarded as a red flag and necessitates referral?in his A Age B Diabetes Mellitus C Gradual Onset Back Pain D HIV SBA Which modality is typically he last to be blockedery complaining of back pain. This has been going on for a while and is troubling him in his work as medical history of gout, T2DM, HIV and stage 1 CKD. Which factor in hisst presentation is regarded as a red flag and necessitates referral? A B C D HIV Redflags • Steroid use history • Osteoporosis • Paget’s disease • Illness/infection serious and recent • Widespread neurological deficit • Non-mechanical pain • HIV/AIDS • Cancer history • History of significant trauma/injury • Alcohol/drug abuse • Fail to improve with treatment • Thoracic pain • Unexplained weight loss/fevers • New onset pain <16yo or >50yo • End stage renal disease • Spinal deformity • SPINC FUNES O WHAT SBA Killua is a 12-year-old male who came into the ED complaining of severe back pain, fever, distal muscle weakness and refusal to weight bear. The registrar orders a set of bloods and imaging that confirm his suspicions. agent of the child’s condition?, what is the most common causative A Enterobacter B Epstein Bar Virus C Meningococcus D Staphylococcus Aureus SBA Which modality is typically the last to be blockedcomplaining of severe back pain, fever, distal muscle weakness and refusal to weight bear. The Given the most likely diagnosis, what is the most common causative agent. of the child’s condition? A B C D Staphylococcus Aureus Spinalepiduralabscess Presentation: Investigation: – Fever – Blood culture – Back pain – Biopsy – Focal neurological deficits – MRI depending on spinal level – Children – refuse weight bear, hip Management: pain, diffuse abdominal pain Pathophysiology: – Broad spectrum antibiotics – Infection spread – Surgical removal of abscess haematogenous, contiguously, through direct implantation or disc involvement – Staph aureus is most common causative organism – Pyogenic infection – Discitis Spondylolysis/listhesis Spondylolysis Spondylolisthesis • Congenital or acquired crack or • One vertebra is displaced relative stress fracture of the pars to its immediate inferior vertebral interarticularis of the neural body arch of a particular vertebral • May occur as a result of stress body fracture or spondylolysis • usually affects L4/ L5 • Treatment depends upon the extent of deformity and • May be asymptomatic associated neurological symptoms; minor cases may be • Spondylolysis is the actively monitored. commonest cause of spondylolisthesis in children • Individuals with radicular • Asymptomatic cases do not symptoms or signs will usually require spinal decompression and require treatment stabilisation SBA Draken is an 18-year-old male who comes into the ED with concerning symptoms. After examination, the registrar concludes that he has a lesion in his corticospinal tract causing muscle weakness, spasticity, rigidity and hyperactive reflexes on the type of motor neuron lesion is the patient exhibiting? the corticospinal tract and what A Lesion caudal to the decussation of tract – upper motor neuron lesion B Lesion cranial to the decussation of tract – upper motor neuron lesion C Lesion caudal to the decussation of tract – lower motor neuron lesion D Lesion caudal to the decussation of tract – upper & lower motor neuron lesion ADraken is an 18-year-old male who comes into the ED with concerning symptoms.the ward. He SBA sAfter examination, the registrar concludes that he has a lesion in his corticospinal3 mtract causing muscle weakne s, spasticity, rigidity and hyperactive reflexes on the returns to normal.to the lesion. Where is the lesion on the corticospinal tract and what At which spinal cord level has the patient most likely been inj?red A Lesion caudal to the decussation of tract – upper motor neuron lesion B C DCorticospinaltractSpinothalamictractDorsalcolumn PosteriorCordsyndrome • Commonly caused by tumour compression • Loss of dorsal column sensory modalities bilaterally AnteriorCordsyndrome • Loss of spinothalamic and corticospinal modalities bilaterally • Injury or occlusion to the anterior spinal artery • Upper motor neuron lesion – spastic paralysis Content • Typically caused by central Crushing of the spinal cord due to compression or traumatic injuries • Typically cause loss of sensory modalities off the lateral spinothalamic tract And spastic paralysis In a Cape like distribution affecting the upper limbs more than the lower limbs Thank You! Follow our Socials: Instagram: @cu_cardiosoc Facebook: Cardiff University Cardiovascular Society Cardiovascularsociety@outlook.com SBA Howmanyunfusedvertebralsegmentsarethereinthehumanspine A 24 B 25 C 28 D 33 SBA SBAquestion:jgvvjx,e,jd Xjgsv,jgve egfvh3gecdh,: A B Text C D SBA SBAquestion:jgvvjx,e,jd Xjgsv,jgve egfvh3gecdh,: A B Text Explanatin (optional)- delete if u want C DSBA SBAquestion:jgvvjx,e,jd Xjgsv,jgve egfvh3gecdh,: A Text B Text C Text D TextSBA SBAquestion:jgvvjx,e,jd Xjgsv,jgve egfvh3gecdh,: Text A B Text why C Text D Text Content Text Text Text Text TextContent TextContent-wouldbegoodforadiagram? Text Comparestuff/summaries Text Text Cellstuffforpcs-animatestuffin Text Text