Spine Surgery
Concepts
Spine questions test separating mechanical from neurologic disease and identifying emergencies. Radiculopathy follows a dermatomal and myotomal pattern, worsens with extension and rotation, and may show a positive Spurling test. Myelopathy produces upper motor neuron signs - hyperreflexia, Hoffmann, Babinski, clonus, gait disturbance, clumsy hands - and is an urgent referral. Cauda equina syndrome means saddle anesthesia, urinary retention or incontinence, bilateral leg pain and weakness; it is an emergency requiring urgent MRI and decompression.
Red flags: fever, weight loss, night pain, intravenous drug use, immunosuppression, trauma, known cancer, age over 50 with new pain, and progressive deficit. Know the ASIA scale for traumatic injury, and that the thoracolumbar junction is the most common site for osteoporotic compression fractures.
Degenerative conditions: stenosis causes neurogenic claudication relieved by sitting and flexion, whereas vascular claudication is relieved by standing still. Know spondylolisthesis grading and when fusion is added to decompression. Scoliosis: Cobb angle measurement, and thresholds for bracing and surgery.
Traps: attributing foot drop or bowel and bladder change to sciatica and delaying imaging; operating early on axial back pain without neurologic findings.
Worked example: a 62-year-old with bilateral thigh pain, urinary retention and decreased perineal sensation has cauda equina syndrome until proven otherwise - emergent MRI, not physical therapy.