Summary
Highlights
Dr. Chung Weng Hong introduces five crucial symptoms to look for when taking a spine history: pain (location, type, mechanical vs. organic, instability), limb pain (upper/lower, unilateral/bilateral, dermatomal distribution, claudication), weakness (monoplegia, paraplegia, tetraplegia, progression over time), numbness (sensory level, very important for localization), and bowel/urinary symptoms (spectrum from urgency to incontinence).
Red flag symptoms signify an emergency or a serious underlying condition. These include extreme age (too young or too old), trauma, axial thoracic back pain (especially if chronic, suggesting tumor or infection), history of malignancy, prolonged steroid use, drug abuse, immunosuppression (HIV), constitutional symptoms (night sweats, rest pain, weight loss, loss of appetite), progressive neurological symptoms, End-Stage Renal Failure (ESRF) on dialysis (high risk of spine infection), rest pain, night pain, and osteoporosis.
A 52-year-old lady presents with bilateral lower limb weakness and numbness (extending to the umbilical level, T10), sudden onset mid-thoracic back pain for two days, and no bowel or bladder incontinence. Her past history includes lower back pain in August 2020. The provisional diagnosis is thoracic myelopathy due to spinal cord compression at T11 (anatomical diagnosis), with Frankel C neurology, secondary to tumor, infection, or acute disc herniation (pathological diagnosis).
The physical examination reveals tenderness at the T8-T9 level, reduced tone and hyporeflexia in lower limbs but up-going Babinski. Dr. Chung emphasizes the importance of sensory examination for localization, as power indicates severity, not precise level in paraplegia. PR examination is crucial to check perianal sensation, anal tone, and voluntary anal contraction. He also discusses how acute neurological deficits can present with mixed upper and lower motor neuron signs (spinal shock).
Dr. Chung explains the anatomical relationship between spinal cord segments and vertebral levels. The spinal cord is shorter than the vertebral column, ending at L1-L2 vertebral level. Therefore, spinal cord segments are numbered higher than their corresponding vertebral bodies in the cervical and thoracic regions. For example, T8 vertebra corresponds to T11 spinal cord segment. This correlation is vital for surgical planning and imaging localization.
MRI with contrast is performed. Sagittal and axial T2 images show spinal cord compression and hyperintense regions, indicating inflammation and severe canal stenosis. Contrast-enhanced MRI reveals diffuse enhancement at the T8-T9 disc space and surrounding areas, including pre-vertebral and epidural extension, consistent with pyogenic infection. A chest X-ray shows a well-rounded opacity in the right lower lobe with central lucency, suggesting a lung abscess, possibly the source of infection.
Dr. Chung differentiates pyogenic from TB spondylodiscitis based on clinical presentation and imaging. Pyogenic infections are typically acute, with early disc involvement and extensive surrounding abscesses. TB infections are more chronic, with late disc involvement (often preserved disc space), and commonly present with paravertebral or psoas abscesses (cold abscesses). The patient's presentation and imaging suggest pyogenic spondylodiscitis.
The patient's sputum cultures were negative for TB, and blood cultures grew Klebsiella pneumoniae sensitive to Augmentin. Dr. Chung advises against empirical antibiotics until a culture is obtained to avoid masking the infection. Staphylococcus aureus is the most common organism in spine infections. Surgical indications for spondylodiscitis include progressive neurological deficit, severe instability, kyphotic deformity, need for culture/biopsy, failure of conservative treatment, and spinal epidural abscess (especially with neurology).
A 68-year-old Indian gentleman presents with a 3-month history of hip pain, described as radiating from the lateral gluteal region to the lateral thigh (L5 distribution) and from the groin to the anterior thigh and knee (L3 distribution). The patient has had right hip pain for 10 years, worsening in the past 3 months. The pain is shooting, worse with prolonged ambulation and movement, and not relieved by painkillers. He also has right leg numbness and weakness with multiple falls. His past medical history includes diabetes, hypertension, and hypercholesterolemia. He previously underwent a right total knee replacement 8 years ago.
Physical examination shows dependence on a wheelchair, obesity, stoop posture, and tenderness over the lumbar sacral area. Lumbar spine movement is restricted, and a straight leg raise test is positive at 30 degrees (though its interpretation for true radiculopathy is discussed – pain must extend beyond the knee). Neurological exam shows global reduction in right lower limb power (MRC grade 4), potentially due to pain. Hip examination reveals reduced range of motion (flexion to 75 degrees) and pain with all movements. The primary differentials are right hip osteoarthritis, degenerative lumbar spine disease, and possibly iliotibial band syndrome related to the previous knee replacement.
Lumbosacral plain radiographs show degenerative changes including osteophytes and narrowed disc spaces, with a phenomenon called 'vacuum disc' (Knudsen sign), indicating degeneration. Right hip plain radiograph shows some subchondral sclerosis but no clear joint space narrowing or osteophytes, making definitive OA diagnosis difficult from this image alone. The discussion then shifts to radiculopathy management and the concepts of nerve mismatch and matching, specifically traversing versus exiting nerve roots in lumbar versus cervical spine disc prolapse, and ipsilateral versus contralateral listing in acute disc herniation.