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OUTLINE THE PHYSIOLOGY OF BONE HEALTH LO PRESENTED BY JEYIN CHOOI CASE 14 SBA YA LO 1.WHAT IS BEING POINTED OUT INTHIS IMAGE? A Cartilage B Diaphysis C Epiphysis D Metaphysis E Physis 1.WHAT IS BEING POINTED OUT INTHIS IMAGE? A Cartilage B Diaphysis C Epiphysis D Metaphysis E Physis Diaphysis Epiphysis Physis MetaphysisPhysis Growth plate (adolescent) 2.YOUARE INA GP SURGERYAND REVIEWINGA PATIENT.ON EXAMINATIONYOU NOTICEA HORIZONTAL SCARACROSSTHE MIDLINE OFTHE NECK.WHAT ISTHIS PATIENTAS RISK OF DEVELOPING? A Bone pain B Flank pain C Lethargy D Muscle spasms E Osteoporosis 2.YOUARE INA GP SURGERYAND REVIEWINGA PATIENT.ON EXAMINATIONYOU NOTICEA HORIZONTAL SCARACROSSTHE MIDLINE OFTHE NECK.WHAT ISTHIS PATIENTAS RISK OF DEVELOPING? A Bone pain B Flank pain C Lethargy D Muscle spasms E OsteoporosisMidline horizontal scar ⬇ A common complication of thyroid surgery is damage to the parathyroids,causing hypoparathyroidism. Thyroid surgery Low PTH ➡ Low Ca ➡ muscle spasms and paraesthesia around mouth & feet 3.YOUARE ON PLACEMENT UNDERTHE ORTHOPAEDICTEAM.ASYOU SITTHROUGHTHE FRACTURE CLINIC,THE CONSULTANTASKSYOUWHAT STAGE OF BONE HEALINGTAKESTHE LONGESTTIME? A Bone remodelling B Haematoma C Hard callus formation D Inflammation E Soft callus formation 3.YOUARE ON PLACEMENT UNDERTHE ORTHOPAEDICTEAM.ASYOU SITTHROUGHTHE FRACTURE CLINIC,THE CONSULTANTASKSYOUWHAT STAGE OF BONE HEALINGTAKESTHE LONGESTTIME? A Bone remodelling B Haematoma C Hard callus formation D Inflammation E Soft callus formationHaematoma Inflammation Soft callus Hard callus Remodelling Day 1-5 Day 6- 14 2-3 weeks 4 – 8 weeks 6 months to years Secondary Bone Healing 4. A 65-YEAR-OLD WOMAN ATTENDS HER GP SURGERY WORRIED ABOUT OSTEOPOROSIS AFTER HER NEIGHBOR SUFFERED A FALL AND BROKE A LONG BONE. YOU REFER THE PATIENT FOR A DEXA SCAN. WHAT RESULTS ON THE DEXA SCAN WILL INDICATE OSTEOPOROSIS IN THIS PATIENT? A T score more than 1.5 standard deviation below the mean B T score more than 2.5 standard deviation below the mean C Z score more than 1.5 standard deviation below the mean D Z score more than 2.5 standard deviation above the mean E Z score more than 2.5 standard deviation below the mean 4. A 65-YEAR-OLD WOMAN ATTENDS HER GP SURGERY WORRIED ABOUT OSTEOPOROSIS AFTER HER NEIGHBOR SUFFERED A FALL AND BROKE A LONG BONE. YOU REFER THE PATIENT FOR A DEXA SCAN. WHAT RESULTS ON THE DEXA SCAN WILL INDICATE OSTEOPOROSIS IN THIS PATIENT? A T score more than 1.5 standard deviation below the mean B T score more than 2.5 standard deviation below the mean C Z score more than 1.5 standard deviation below the mean D Z score more than 2.5 standard deviation above the mean E Z score more than 2.5 standard deviation below the mean Z-score = adjusted to age,sex,ethnicity T -score = compared healthy 30 y/o adult of same sex and ethnicity (not adjusted to age) Osteoporosis Post-menopausal and men over 50 ➡ T score Younger adults ➡ Z score DEXA = a type of X-ray that measures the bone density,usually at vertebrae or hip Less dense bone but not reaching threshold of 2.5 SD is considered ”pre”- osteoporosis or osteopenia. 5.WHAT DOYOU EXPECTTO SEE INA BONE PROFILE BLOODTEST FORA PATIENT WITH OSTEOMALACIA? Calcium Phosphate Alk Phos PTH High High High Low A B High Low Normal High Low Low Normal High C Normal Normal High Normal D Normal Normal Normal Normal E 5.WHAT DOYOU EXPECTTO SEE INA BONE PROFILE BLOODTEST FORA PATIENT WITH OSTEOMALACIA? Calcium Phosphate Alk Phos PTH High High High Low A B High Low Normal High Low Low Normal High C Normal Normal High Normal D Normal Normal Normal Normal E 6.WHAT ISTHE FOLLOWING STATEMENTS DESCRIBING? - OSTEOCLAST OVERACTIVITY - COMPENSATORY OSTEOBLASTACTIVITY - DISORDERED‘WOVEN’ MOSAIC BONE A Bone metastases B Hyperparathyroidism C Osteomalacia D Osteoporosis E Paget’s disease 6. WHAT IS THE FOLLOWING STATEMENTS DESCRIBING? - OSTEOCLAST OVERACTIVITY - COMPENSATORY OSTEOBLAST ACTIVITY - DISORDERED ‘WOVEN’ MOSAIC BONE A Bone metastases B Hyperparathyroidism C Osteomalacia D Osteoporosis E Paget’s diseaseBone scan showing increased uptake of tracer in Paget’s 7. THE FOLLOWING IMAGE ISAN X-RAY PELVIS OFA MALE PATIENT.WHAT ISTHE MOST LIKELY PRIMARY MALIGNANCY? A Breast B Kidney C Lung D Prostate E Thyroid 7. THE FOLLOWING IMAGE IS AN X-RAY PELVIS OF A MALE PATIENT. WHAT IS THE MOST LIKELY PRIMARY MALIGNANCY? A Breast B Kidney C Lung D Prostate E ThyroidSclerotic = Blastic =‘Bone building’ DESCRIBETHE EPIDEMIOLOGY OF BACK PAIN AND SICKNESS RELATEDABSENCE FROMWORK LO 8. WHAT ARE THE MAIN RISK FACTORS CONTRIBUTING TO BACK PAIN? A Obesity, occupational factors and smoking B Obesity,smoking and stressful life events C Occupational factors,physical inactivity and stressful life events D Occupational factors,smoking and stressful life events E Physical inactivity,smoking and stressful life events 8.WHATARETHE MAIN RISK FACTORS CONTRIBUTINGTO BACK PAIN? A Obesity,occupational factors and smoking B Obesity,smoking and stressful life events C Occupational factors, physical inactivity and stressful life events D Occupational factors,smoking and stressful life events E Physical inactivity, smoking and stressful life eventsRisk factors for the development of non-specific low back pain include (NICE 2022) : • Obesity. • Physical inactivity. • Occupational factors (such as heavy lifting,bending,or twisting). • Stressful life events or depression. 9. HOW TO BEST DESCRIBE THE PREVALENCE OF LOWER BACK PAIN?* A It is more common in under 45y/o vs in over 45y/o B It is more common in women than men C Lower back pain is usually a result of trauma to the spine D Lower back pain is not a self-limiting condition for most people E Lower back pain was reported by 3 in 4 people aged over 80 years 9.HOWTO BEST DESCRIBETHE PREVALENCE OF LOWER BACK PAIN?* A It is more common in under 45y/o vs in over 45y/o B It is more common in women than men C Lower back pain is usually a result of trauma to the spine D Lower back pain is not a self-limiting condition for most people E Lower back pain was reported by 3 in 4 people aged over 80 yearsPrevalence of low back pain (NICE 2022) : • More common in over 45 y/o. • More common in female. • Most of lower back pain does not arise from trauma. • Majority of lower back pain is a self limiting. • Low back pain was reported by 1 in 4 people aged over 80 y/o. 10. HOW LONG CAN YOU ISSUE A SICK NOTE FOR THE PATIENT FOLLOWING A NEW RECENT DIAGNOSIS OF CHRONIC ILLNESS? A ‘An indefinite period’ B 3 weeks C 6 weeks D 3 months E 6 months 10.HOW LONG CANYOU ISSUEA SICK NOTE FORTHE PATIENT FOLLOWINGA NEW RECENT DIAGNOSIS OF CHRONIC ILLNESS? A ‘An indefinite period’ B 3 weeks C 6 weeks D 3 months E 6 monthsYou also do not need to issue a fit note for the first 7 calendar days of a patient’s sickness absence.Patients can self- certify for this period. In the first 6 months of a patient’s condition,a fit note can cover a maximum of 3 months. If a condition has lasted longer than 6 months,a fit note can be for any clinically appropriate period up to‘an indefinite period’. Gov.uk 202211. YOU ARE AN FY ON THE WARDS AND A PATIENT THAT IS ADMITTED WITH DISABLING LOWER BACK PAIN ASKS YOU TO WRITE UP A SICK NOTE FOR HIM. HE CLAIMS THAT HIS BACK PAIN STARTED 2 DAYS BEFORE HE WAS SEEN AND ADMITTED, AND HE IS NOW ON DAY 2 BEING IN THE HOSPITAL. YOU THINK HE NEEDS 2 MORE DAYS TO RECOVER BEFORE SAFELY RETURNING TO WORK. WHAT SHOULD YOU PUT FOR START DATE AND DURATION OF SICK LEAVE? A Start from current day for 2 days B Start from current day for 4 days C Start from day of admission for 4 days D Start from the day symptoms started,for 4 days Start from the day symptoms started,for 6 days E11.YOUAREAN FY ONTHEWARDSANDA PATIENTTHAT ISADMITTEDWITH DISABLING LOWER BACK PAINASKS YOUTOWRITE UPA SICK NOTE FOR HIM.HE CLAIMSTHAT HIS BACK PAIN STARTED 2 DAYS BEFORE HEWAS SEEN ANDADMITTED,AND HE IS NOW ON DAY 2 BEING INTHE HOSPITAL.YOUTHINK HE NEEDS 2 MORE DAYSTO RECOVER BEFORE SAFELY RETURNINGTOWORK.WHAT SHOULDYOU PUT FOR START DATEAND DURATION OF SICK LEAVE? A Start from current day for 2 days B Start from current day for 4 days C Start from day of admission for 4 days D Start from the day symptoms started,for 4 days Start from the day symptoms started, for 6 days EIf you are issuing a fit note based on an assessment conducted at an earlier date,you should enter the date of this earlier assessment in the date of assessment field. If your patient’s condition has affected their function for some time without a previous fit note being issued,you must enter an estimated date that their function was affected from in the‘this will be the case from’ field. APPLY KNOWLEDGEABOUTTHE SOCIALASPECTS OF CHRONIC ILLNESSTO UNDERSTANDING PATIENTS EXPERIENCES OF BACK PAIN,ANDTO CLINICAL PRACTICES OF INFORMATION,SUPPORTAND REFERRAL LO 12.A PATIENT COMESTO SEEYOU INTHE GP SURGERY COMPLAINING OF 3WEEKS INTERMITTENT HISTORY OF LOWER BACK PAIN.ON HISTORYAND EXAMINATION,YOU DID NOT FINDANY RED FLAG SYMPTOMS. WHAT ISTHE MOSTAPPROPRIATE MANAGEMENT? A Arrange spinal specialist referral B Advise to use opioids for pain management C Encourage for bed rest and review again in 1 week D Offer advice on exercise programme such as swimming E Refer for radiofrequency denervation 12. A PATIENT COMES TO SEE YOU IN THE GP SURGERY COMPLAINING OF 3 WEEKS INTERMITTENT HISTORY OF LOWER BACK PAIN. ON HISTORY AND EXAMINATION, YOU DID NOT FIND ANY RED FLAG SYMPTOMS. WHAT IS THE MOST APPROPRIATE MANAGEMENT? A Arrange spinal specialist referral B Advise to use opioids for pain management C Encourage for bed rest and review again in 1 week D Offer advice on exercise programme such as swimming E Refer for radiofrequency denervationAns: Offer advice on exercise programme such as swimming NICE 2022: “Offer advice on exercise programmes, manual therapy, and/or psychological support” Arrange spinal specialist referral - If symptoms persist after 3/4 weeks with self-management strategies and drug treatments Advise to use opioids for pain management - Opioids, Benzodiazepines, gabapentin, antiepileptic, antidepressants and Paracetamol are not recommended - NSIADS such as Ibuprofen are preferred for the shortest possible time Encourage for bed rest and review again in 1 week - Prolonged bed rest or inactivity is associated with worse outcomes Refer for radiofrequency denervation - If a person has chronic low back pain and non-invasive treatments are ineffective ➡ consider refer to specialist back pain service including possible radiofrequency denervation 13.YOU RECENTLY DIAGNOSEA PATIENTWITH SCIATICA.THIS PATIENT USUALLY DRIVESA CAR FOR PERSONAL USE. WHAT ISYOUR PROFESSIONAL RESPONSIBILITY IN REGARDTOTHE PATIENT DRIVINGWITHA MEDICAL CONDITION? A Discuss with patient to report to DVLA immediately but free to drive after done so B Discuss with patient to stop driving immediately and report to DVLA C Discuss with patient to stop driving until next review in 3 weeks time D No further action required E Report to DVLA on behalf of the patient 13.YOU RECENTLY DIAGNOSEA PATIENTWITH SCIATICA.THIS PATIENT USUALLY DRIVESA CAR FOR PERSONAL USE. WHAT ISYOUR PROFESSIONAL RESPONSIBILITY IN REGARDTOTHE PATIENT DRIVINGWITHA MEDICAL CONDITION? A Discuss with patient to report to DVLA immediately but free to drive after done so B Discuss with patient to stop driving immediately and report to DVLA C Discuss with patient to stop driving until next review in 3 weeks time D No further action required E Report to DVLA on behalf of the patientSciatica is not a health condition that warrants the patient to declare to DVLA. Some health conditions that can impact patient’s judgment or trigger sudden drastic changes to the stability of the patient requires the patient to report this to the DVLA, usually still able to drive if medically fit to do so. For bus, lorry or coach licence holder, the rules are more strict and requires the licence holder to report to DVLA immediately and stop driving until approved by DVLA. 14.A PATIENTWITH BACK PAIN,NOWTREATED,ISWORRIEDABOUT GOING BACKTOWORK.HE HAS BEEN SYMPTOM FREEAND MEDICALLY FIT SINCETREATMENTANDWORKS INA SUPERMARKET.HE HAS BEEN OFFWORKWITHA SICK NOTEANDWANTSTO REST FOR 2 MORE WEEKS BEFORE STARTING HIS JOBAGAIN.WHAT ISYOUR MOSTAPPROPRIATEACTION? A Discuss with the patient to take time off work until feel ready to do so B Reassure the patient that work is good for rehabilitation C Refer the patient for occupational health assessment D Write a fit note stating the patient may be fit for work if on modified duties E Write a sick note of 2 more weeks for the patient 14.A PATIENTWITH BACK PAIN,NOWTREATED,ISWORRIEDABOUT GOING BACKTOWORK.HE HAS BEEN SYMPTOM FREEAND MEDICALLY FIT SINCETREATMENTANDWORKS INA SUPERMARKET.HE HAS BEEN OFFWORKWITHA SICK NOTEANDWANTSTO REST FOR 2 MORE WEEKS BEFORE STARTING HIS JOBAGAIN.WHAT ISYOUR MOSTAPPROPRIATEACTION? A Discuss with the patient to take time off work until feel ready to do so B Reassure the patient that work is good for rehabilitation C Refer the patient for occupational health assessment D Write a fit note stating the patient may be fit for work if on modified duties E Write a sick note of 2 more weeks for the patientWork is therapeutic and an essential part of recovery. Patients usually should be encouraged and supported to return to work as early as possible, even with some symptoms. Sick notes can only be issued on the basis of health conditions. Eg: ‘Distress due to bereavement’ is acceptable if the patient is stressed resulting in ill health. • EXPLAINTHE DIFFERENCE BETWEEN UPPERAND LOWER MOTOR LESIONS • EXPLAINTHE PATHOLOGICAL MECHANISMS RESPONSIBLE FORTHE DEVELOPMENT OF BACK-PAIN • DESCRIBETHE FEATURES OF MEDICALLY SIGNIFICANT CAUSES OF BACK PAIN IN THEADULTANDTHE CHILD (RED FLAG SYMPTOMSAND SIGNS) INCLUDING LO METASTATIC DISEASE,SPINAL INFECTION,SPINALTRAUMAAND CAUDA EQUINA SYNDROME PRESENTED BY SANDRA A 32-YEAR-OLDWOMAN PRESENTSWITH SPASTICAND RIGID MUSCLETONE, ABSENT FASCICULATIONSAND HYPERREFLEXIA. WHAT ISTHE CAUSE OFTHIS PRESENTATION? A Spinal cord injury B Upper motor neuron lesion C Multiple sclerosis D Lower motor neuron lesion E Peripheral neuropathy A 32-YEAR-OLD WOMAN PRESENTS WITH SPASTIC AND RIGID MUSCLE TONE, ABSENT FASCICULATIONS AND HYPERREFLEXIA. WHAT IS THE CAUSE OF THIS PRESENTATION? A Spinal cord injury B Upper motor neuron lesion C Multiple sclerosis D Lower motor neuron lesion E Peripheral neuropathy A 46-YEAR-OLD MAN PRESENTSWITH PROXIMAL MYOPATHY,HYPOTONIAAND HYPOREFLEXIA. WHAT ISTHETYPE OF LESIONA ND SITE? A LMN - cerebellum B UMN – spinal cord C LMN – spinal cord D UMN - brainstem E LMN – neuromuscular junction A 46-YEAR-OLD MAN PRESENTS WITH PROXIMAL MYOPATHY, HYPOTONIA AND HYPOREFLEXIA. WHAT IS THE TYPE OF LESIONA ND SITE? A LMN - cerebellum B UMN – spinal cord C LMN – spinal cord D UMN - brainstem E LMN – neuromuscular junction A PATIENT PRESENTS WITH A TUMOR THAT HAS SPREAD TO THE SPINE. WHICH IS THE CORRECT SITE, FORM OF TRANSMISSION AND METASTATIC SITE IN THE LIST BELOW? Lung – segmental - thoracic B Lung – azygous - thoracic C Breast – azygous - lumbar D Breast – segmental - thoracic E Prostate – pelvic venous plexus - lumbar A PATIENT PRESENTSWITHATUMORTHAT HAS SPREADTOTHE SPINE.WHICH ISTHE CORRECT SITE,FORM OFTRANSMISSIONAND METASTATIC SITE INTHE LIST BELOW? A Lung – segmental - thoracic B Lung – azygous - thoracic C Breast – azygous - lumbar D Breast – segmental - thoracic E Prostate – pelvic venous plexus - lumbar WHAT IS THE BASTON VENOUS PLEXUS? A A group of veins in the pelvis B Anastomoses of arteries at low pressure C Small veins with no valves D Small arteries at low pressure E Anastomoses of veins at high pressure WHAT IS THE BASTON VENOUS PLEXUS? A A group of veins in the pelvis B Anastomoses of arteries at low pressure C Small veins with no valves D Small arteries at low pressure E Anastomoses of veins at high pressureMETASTASES 3 mechanisms of metastases: • Bloodstream or lymphatics • Breast - azygous - thoracic • Lung - segmental - thoracic • Prostate - pelvic venous plexus - lumbar • Batson venous plexus • Small,no valves,low pressure • Direct spread A 7-YEAR-OLD CHILD PRESENTS WITH NONSPECIFIC HIP PAIN, BELLY PAIN AND REFUSAL TO WEIGHT BEAR. HE HAS NO FEVER. WHAT IS A LIKELY CAUSE OF HIS PRESENTATION? A Flu B Appendicitis C Spinal infection D Spinal metastases E Pelvic infection A 7-YEAR-OLD CHILD PRESENTS WITH NONSPECIFIC HIP PAIN, BELLY PAIN AND REFUSAL TO WEIGHT BEAR. HE HAS NO FEVER. WHAT IS A LIKELY CAUSE OF HIS PRESENTATION? A Flu B Appendicitis C Spinal infection D Spinal metastases E Pelvic infectionSPINAL INFECTION Typical presentation in adults Typical In children: •Pain •Fever •Hip pain,belly pain,non- •Neuro deficits •ALL 3 = EPIDURAL ABSCESS (significant mortality risk if untreated, thoracic most specific,refusal to weight common) bear People who are most likely to get infections of spine •<50% have fevers •Diabetics/ Druggie •Immunosuppressed/ Immigrant •Steroids/spinal surg •Genitourinary issue - recurrent UTI •Renal F/rheumatoid (immuno) •Adolescents •Cardiac issues -spread •Elderly GOOD DISC BAD NEWS - not infection, maybe CANCER BAD DISC GOOD NEWS - infection WHAT DOESTHIS IMAGE SHOW? A Kyphosis B Fracture at L5/S1 C Spondylosis D Spondylisthesis E Scoliosis WHAT DOES THIS IMAGE SHOW? A Kyphosis B Fracture at L5/S1 C Spondylosis D Spondylolisthesis E Scoliosis SPONDYLOLISTHESIS Vertebrae‘slipped’ on top of other - front slip over bottom Development or acquired • Bilateral pars defect,nothing connecting anterior/posterior bony elements. • With age,disc undergo degenerative change,lose height • Forwards slip occurs • Gap in pars widen + spinal canal widen •Asymptomatic High grade or low grade •LBP, buttock, thigh, groin •+/radicular pain • <50% slippage - low grade •+/- numbness l5-s1 (common) • 50% - high grade •+/- urinary/bowel •restricted motion, hyperlordosis (+ compensated kyphosis above), palpable step, WHAT IS THE MANAGEMENT FOR CAUDA EQUINA? A Surgical decompression B Physiotherapy C Spinal fusion D Vertebroplasty E Disectomy WHAT IS THE MANAGEMENT FOR CAUDA EQUINA? A Surgical decompression B Physiotherapy C Spinal fusion D Vertebroplasty E DisectomyCAUDA EQUINA • Red flags • Saddle anaesthesia (no sensation in perineum) •What do nerves of cauda equina supply? • Urinary incontinence - loss of sensation in bladder leads to it • Sensation - Bladder+rectum,perineum+lower limb • Faecal incontinence • Motor - urethral+anal sphincters,lower limbs • Bilateral sciatica, motor weakness • Parasympathetic - bladder+rectum • Reduced anal tone on PR examination • Management • Hospital • MRI • Lumbar decompression surgery • Causes? • Herniated disc (lumbar) • Tumour - metastases • Spondylolisthesis • Abscess • Trauma LO: DESCRIBE THE STRUCTURE AND FUNCTION OF THE BACK AND SPINE LO RD PRESENTED BY BENJAMINYI YEAR MEDICAL STUDENT IDENTIFY THE STRUCTURE LABELLED 2 A Vertebral Body B Pedicle C Lamina D Spinous Process E Vertebral Foramen IDENTIFY THE STRUCTURE LABELLED 2 A Vertebral Body B Pedicle C Lamina D Spinous Process E Vertebral ForamenQ1 ¡ Laminectomy – to manage spinal stenosis WHICH OF THE FOLLOWING IS CLASSIFIED AS A CERVICAL VERTEBRA? A Presence of demi-facets on each side of a heart shaped vertebral body B An inverted triangle shape,formed by the fusion of five vertebrae C Large kidney shaped vertebral body with no costal facets D Bifid spinous process with two transverse foramen E The terminal part of the vertebral column,attached to the gluteus maximus WHICH OF THE FOLLOWING IS CLASSIFIED AS A CERVICAL VERTEBRA? A Presence of demi-facets on each side of a heart shaped vertebral body B An inverted triangle shape,formed by the fusion of five vertebrae C Large kidney shaped vertebral body with no costal facets D Bifid spinous process with two transverse foramen E The terminal part of the vertebral column,attached to the gluteus maximusQ2 Presence of demi-facets on each side of a heart shaped vertebral body – thoracic vertebra An inverted triangle shape, formed by the fusion of five vertebrae – sacrum Large kidney shaped vertebral body with no costal facets – lumbar vertebra Bifid spinous process with two transverse foramen – cervical vertebra The terminal part of the vertebral column, attached to the gluteus maximus – coccyxA 5YEAR OLD PRESENTSTOA&EWITH NECK STIFFNESS,PHOTOPHOBIAANDTEMPERATURE OF 38.1°C. A LUMBAR PUNCTUREWAS PERFORMED FOR SUSPECTED MENINGITIS WHAT’STHE CORRECT ORDER OF LUMBAR PUNCTURE NEEDLE COURSE? A Supraspinous Ligament,Ligamentum Flavum,Interspinous Ligament,Epidural Space,Dura Mater, Arachnoid Mater,Subarachnoid Space B Supraspinous Ligament,Interspinous Ligament,Ligamentum Flavum,Epidural Space,Dura Mater, Arachnoid Mater,Subarachnoid Space C Supraspinous Ligament, Ligamentum Flavum, Interspinous Ligament, Epidural Space, Arachnoid Mater, Dura Mater, Subdural Space D Supraspinous Ligament, Interspinous Ligament, Ligamentum Flavum, Epidural Space, Arachnoid Mater, Dura Mater, Subdural Space E Ligamentum Flavum,Interspinous Ligament,Supraspinous Ligament,Epidural Space,Dura Mater, Arachnoid Mater,Subarachnoid SpaceA 5YEAR OLD PRESENTSTOA&EWITH NECK STIFFNESS,PHOTOPHOBIAANDTEMPERATURE OF 38.1°C. A LUMBAR PUNCTUREWAS PERFORMED FOR SUSPECTED MENINGITIS WHAT’STHE CORRECT ORDER OF LUMBAR PUNCTURE NEEDLE COURSE? Supraspinous Ligament,Ligamentum Flavum,Interspinous Ligament,Epidural Space,Dura Mater, A Arachnoid Mater,Subarachnoid Space B Supraspinous Ligament,Interspinous Ligament,Ligamentum Flavum,Epidural Space,Dura Mater, Arachnoid Mater,Subarachnoid Space Supraspinous Ligament,Ligamentum Flavum,Interspinous Ligament,Epidural Space, Arachnoid C Mater,Dura Mater,Subdural Space D Supraspinous Ligament, Interspinous Ligament, Ligamentum Flavum, Epidural Space, Arachnoid Mater, Dura Mater, Subdural Space Ligamentum Flavum, Interspinous Ligament, Supraspinous Ligament, Epidural Space, Dura E Mater, Arachnoid Mater, Subarachnoid SpaceQ3 MICHAELWAS USING HIS PHONEWHILE DRIVINGAND GOT INTOA CARACCIDENT.THIS GAME HIMA HYPEREXTENSION INJURY ON HIS SPINE. WHICH LIGAMENT INTHE SPINE USUALLY LIMITSTHIS MOVEMENT? A Ligamentum Flavum B Interspinous Ligament C Anterior Longitudinal Ligament D Posterior Longitudinal Ligament E Supraspinous LigamentMICHAELWAS USING HIS PHONEWHILE DRIVINGAND GOT INTOA CARACCIDENT. THIS GAME HIMA HYPEREXTENSION INJURY ON HIS SPINE. WHICH LIGAMENT INTHE SPINE USUALLY LIMITSTHIS MOVEMENT? A Ligamentum Flavum B Interspinous Ligament C Anterior Longitudinal Ligament D Posterior Longitudinal Ligament E Supraspinous LigamentQ4 ¡ Imagine neck bending backwards, would stretch the anterior longitudinal ligament which creates tension but prevents hyperextension WHAT ISTHE MAIN FUNCTION OFTHE POSTERIORVERTEBRAL COLUMN A Support B Stability C Shock absorber D Compression E Tension Band WHAT ISTHE MAIN FUNCTION OFTHE POSTERIORVERTEBRAL COLUMN A Support B Stability C Shock absorber D Compression E Tension BandQ5 From Introduction to Case 14 Lecture LO: OUTLINE THE FUNCTIONAL ANATOMY AND PHYSIOLOGY OF THE SPINAL CORD AND PERIPHERAL NERVES LO PRESENTED BY BENJAMIN YI HOONGYEAR MEDICAL STUDENT A PATIENTWITHAMYOTROPHIC LATERAL SCLEROSIS PRESENTSWITH MUSCLEATROPHYAND WASTING. WHICH SPINALTRACTWHEN DAMAGED CAN CONTRIBUTETOTHIS FINDING? A Lateral corticospinal B Lateral spinothalamic C Anterior spinothalamic D Anterior spinocerebellar E Lateral spinocerebellar A PATIENTWITHAMYOTROPHIC LATERAL SCLEROSIS PRESENTSWITH MUSCLEATROPHYAND WASTING. WHICH SPINALTRACTWHEN DAMAGED CAN CONTRIBUTETOTHIS FINDING? A Lateral corticospinal B Lateral spinothalamic C Anterior spinothalamic D Anterior spinocerebellar E Lateral spinocerebellarQ1 ¡ The lateral corticospinal tract is a descending motor pathway (begins in cerebral cortex and decussates in medulla) ¡ The rest are ascending sensory pathways ¡ Muscle atrophy is a lower motor neurone sign therefore damage to motor pathway A 25YEAR OLD MALE PRESENTSTOA&EAFTER BEING INVOLVED INA SEVERE ROADTRAFFIC ACCIDENT. YOU SUSPECT HE HAS SPINAL SHOCK. WHICH REFLEXWOULD BE BESTTO ELICITTOTEST FORTHIS? A Knee-jerk reflex B Bicep reflex C Bulbocavernosus reflex D Babinski reflex E Ankle reflex A 25YEAR OLD MALE PRESENTSTOA&EAFTER BEING INVOLVED INA SEVERE ROADTRAFFIC ACCIDENT. YOU SUSPECT HE HAS SPINAL SHOCK. WHICH REFLEXWOULD BE BESTTO ELICITTOTEST FORTHIS? A Knee-jerk reflex B Bicep reflex C Bulbocavernosus reflex D Babinski reflex E Ankle reflexQ2 ¡ Spinal shock – all motor and sensory loss below level of injury (areflexia, flaccid paralysis, lack of sensation) ¡ Bulbocavernosus reflex is best to check for spinal shock – if absent, likely spinal shock ¡ Bulbocavernosus arc involves S2-S4 spinal reflex arc (lowest reflex) ¡ Cauda equina syndrome – LMN signs (S1-S4 loss of function) • Bilateral sciatica • Loss of ankle and knee reflex (because of S1-S4 loss of function) • Bladder and bowel dysfunction • ProgressiveJAMIE’S HAND IS INJURED FROMA HEAVYWEIGHT DROPPING ON HIS HANDWHILEATTHE GYM. THE DAMAGED NERVE HAS LOSS OF AXONALAND ENDONEURAL CONTINUITY. A FEW MONTHS LATER, TAPPING HISARMALONGTHE SITE OF INJURY GIVES HIMATINGLING SENSATION 3 CM DISTALLYTHAN HE DID ATTHETIME OF INJURY. WHAT ISTHE MOST LIKELY DIAGNOSIS? A SunderlandType 1 B Sunderland Type II C SunderlandType III D SunderlandType IV SunderlandTypeV EJAMIE’S HAND IS INJURED FROMA HEAVYWEIGHT DROPPING ON HIS HANDWHILEATTHE GYM. THE DAMAGED NERVE HAS LOSS OF AXONALAND ENDONEURAL CONTINUITY. A FEW MONTHS LATER, TAPPING HISARMALONGTHE SITE OF INJURY GIVES HIMATINGLING SENSATION 3 CM DISTALLYTHAN HE DID ATTHETIME OF INJURY. WHAT ISTHE MOST LIKELY DIAGNOSIS? A SunderlandType 1 B SunderlandType II C Sunderland Type III D Sunderland Type IV SunderlandTypeV E Q3 From ‘Nerve Anatomy, Physiology and Response to Injury’ Plenary ¡ OnlyType II and III haveAdvancingTinel’s LO:DESCRIBETHEANATOMICAL RELATIONSHIP OFTHE SPINAL CORDAND PERIPHERAL NERVE ROOTSTOTHE VERTEBRAL COLUMN LO PRESENTED BY BENJAMINYI HYEAR MEDICAL STUDENT WHATVERTEBRAL LEVEL DOESTHE SPINAL CORDTERMINATE INADULTS? A L1-L2 B L3-L4 C L4-L5 D L5-S1 E S1-S2 WHATVERTEBRAL LEVEL DOESTHE SPINAL CORDTERMINATE INADULTS? A L1-L2 B L3-L4 C L4-L5 D L5-S1 E S1-S2Q1 ¡ In adults,the spinal cord ends at L1-L2 level ¡ This is why lumbar punctures are usually done at a lower level (around L4) to avoid damaging the spinal cord ¡ In children,the spinal cord ends lower because they are still developing (around L3-L5)A MEDICAL STUDENT ISASKEDTO LABELTHE NERVE ROOTS ON LATERAL CERVICAL SPINE X RAY. WHICH NERVE EXITSATTHE LEVEL MARKED BYTHEARROW? A C1 B C2 C C4 D C5 E C6A MEDICAL STUDENT ISASKEDTO LABELTHE NERVE ROOTS ON LATERAL CERVICAL SPINE X RAY. WHICH NERVE EXITSATTHE LEVEL MARKED BYTHEARROW? A C1 B C2 C C4 D C5 E C6 Q2 C1 ¡ Above C7 vertebra, nerve root sits above vertebrae it is named after C6 nerve root C6 Vertebra Prominens (C7) C7YOU ARE LOOKING AT A MRI LUMBAR SPINE OF A 60 YEAR OLD MALE. THE NERVE EXITING THE LEVEL MARKED BY THE ARROW IS DAMAGED. WHICH NERVE HAS BEEN DAMAGED? A L1 B L2 C L3 D L4 E L5YOUARE LOOKINGATA MRI LUMBAR SPINE OFA 60YEAR OLD MALE.THE NERVE EXITINGTHE LEVEL MARKED BYTHEARROW IS DAMAGED. WHICH NERVE HAS BEEN DAMAGED? A L1 B L2 C L3 D L4 E L5 Q3 ¡ BelowT1 vertebra,nerve root L1 sits below vertebrae it is named after L2 L3 L3 nerve root L4 L5 * S1 *A 28YEAR OLD MALE DEVELOPS LOW BACK PAIN RADIATING DOWN RIGHT LEG.EXAMINATION SHOWSABSENT RIGHTANKLE REFLEX,WEAKNESS OF RIGHT KNEE FLEXIONAND PLANTARFLEXIONWITH LOSS OF SENSATION OVER RIGHT LATERAL FOOTAND POSTERIOR LEG.AN MRI LUMBAR SPINE IS DONE. WHAT RADICULOPATHY ISTHE PATIENT MOST LIKELY EXPERIENCING? A L3 B L4 C L5 D S1 E L2A 28YEAR OLD MALE DEVELOPS LOW BACK PAIN RADIATING DOWN RIGHT LEG.EXAMINATION SHOWSABSENT RIGHTANKLE REFLEX,WEAKNESS OF RIGHT KNEE FLEXIONAND PLANTARFLEXIONWITH LOSS OF SENSATION OVER RIGHT LATERAL FOOTAND POSTERIOR LEG.AN MRI LUMBAR SPINE IS DONE. WHAT RADICULOPATHY ISTHE PATIENT MOST LIKELY EXPERIENCING? A L3 B L4 C L5 D S1 E L2Q4 What is the most likely diagnosis? L5/S1 disc prolapse Q4 ¡ L5/S1 disc prolapse is most Why is it most likely S1 radiculopathy? likely posterolateral ¡ Hence, this affects the traversing nerve root (S1) instead of the exiting nerve root (L5) L4 vertebra ¡ Extra clue in question stem: absence of ankle reflex suggests S1 radiculopathy! Posterolateral disc herniation (95%) – affects the L5/S1 disc prolapse traversing nerve root (the nerve root that will exit below the next vertebra) Foraminal disc herniation (5%) – affects the exiting nerve root