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Y1 TP2 Musculoskeletal System > 1. The Lumbar Spine > Flashcards

1. The Lumbar Spine Flashcards

1
Q

The back

A

Posterior part of the trunk, inferior to neck and superior to gluteal region

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2
Q

Vertebral column

A

made up of vertebrae and intervertebral discs (approx. ¼ L)

Extends from cranium to apex of coccyx

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3
Q

What supports the weight anterior to the vertebral column

A

• -> Most weight is anterior to column - supported posteriorly by numerous and powerful muscles attached to strong spinous and transverse processes

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4
Q

4 Functions of the vertebral column

A
  • Protection of the spinal cord and the cauda equina
  • Supports the weight of the body above the pelvis
  • Posture and Movement - Highly flexible structure of bones, intervertebral discs and ligaments
  • Haemopoiesis – red marrow, blood cell production
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5
Q

Structure of vertebral column

A

Typically 33 vertebrae:
• 7 cervical
• 12 thoracic
• 5 lumbar
• *5 sacral = In adults, 5 sacral vertebrae form the sacrum
• *4 coccygeal = After 30, 4 coccygeal vertebrae form the coccyx

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6
Q

Mobile areas of vertebral column

A

Cervical and lumbar

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7
Q

Immobile area of vertebral column

A

Thoracic

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8
Q

Structure of typical vertebrae

A

• Anterior = vertebral body
• Posterior – vertebral arch
• Vertebral foramen , when vertebrae are stacked on eachother – forms vertebral canal: contains spinal cord and roots of spinal nerves along with meninges, fat and vessels
• Transverse process on either side x2
• Spinous process
Transverse and spinous process provide attachment
• Pedicles – connect transverse process to vertebral body
• Laminae (flat bone) connect transverse process to spinous process
Pedicle + lamina = vertebral arch

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9
Q

Vertebral foramen

A

• Vertebral foramen , when vertebrae are stacked on eachother – forms vertebral canal: contains spinal cord and roots of spinal nerves along with meninges, fat and vessels

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10
Q

Vertebral body

A

—> largest part of vertebrae
Made of compact and cancellous bone and bone marrow
• Usually main weight bearing part of vertebra
• Superior and inferior surfaces covered with hyaline cartilage
• Linked to adjacent vertebral bodies by intervertebral discs (i.e. secondary cartilaginous joints)
• Size of bodies increases as the column descends, L5 body is taller anteriorly – largely responsible for lumbosacral angle

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11
Q

Intervertebral foramen

A

where the spinal nerves leave spinal canal
• Sup & Inf vertebral notches – indentations (sup and inf) in each pedicle
• Posteriorly (sup and inf) articular processes and anteriorly v. body and iv disc

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12
Q

2 Transverse processes

A
  • left and right
    • project posterior-laterally
    • arise from junction of pedicles and laminae

Provide attachment for deep muscles

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13
Q

1 Spinous process

A

• projects posteriorly & usually inferiorly

Provide attachment for deep muscles

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14
Q

4 Articular processes

A
  • 2 superior and 2 inferior
    • arise from junction of pedicles and laminae
    • each with a articular facet
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15
Q

How many processes are there

A

7 Processes Arise from the Arch

  • 1 Spinous process
  • 2 Transverse processes
  • 4 Articular processes
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16
Q

Zygapophysial joints

A

• (Zygapophysial joints) = Plane synovial joints, lined by hyaline cartilage

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17
Q

Facet joints - structure

A
  • (Zygapophysial joints) = Plane synovial joints, lined by hyaline cartilage
    • Paired
    • Articular processes and joints determine type of movement
    • Orientated in a sagittal plane
    • inferior articular process of vertebra above faces laterally
    • Superior processes of vertebra below face medially
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18
Q

Facet joints - function

A
  • Allows flexion, extension and lateral flexion – but prohibits rotation
    • Nerve supply and blocks – can be used to treat facet pain
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19
Q

What is the sacrum

A

—> inferior part of spine
Wedge shaped formed from 5 fused sacral vertebrae
• Articulates with L5 superiorly, ilium laterally, and coccyx inferiorly

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20
Q

Sacral canal

A

= continuation of vertebral canal

• contains bundle of spinal roots (inferior to L1) known as cauda equina (L. horsetail)

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21
Q

Sacrum- structure

A
  • 4 paired sacral foramina – anterior and posterior
  • Base of sacrum, superior surface of S1 articulates with inf articular process of L5
  • Sacral promontory – ant projection= imp obstetric landmark
  • Sacral hiatus (U-shaped; absence of laminae and spinous processes of S5 & sometimes S4) leads into spinal canal.
    • Sacral cornua on either side
  • Auricular surface (L, external ear) – synovial sacroiliac joint
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22
Q

Coccyx structure

A

—> Consists of 4 fused vertebrae
• Coccygeal vertebra 1 = Largest/ broadest, may remain separate from other 3
• Last 3 fuse to form beak like structure

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23
Q

Coccyx function

A
  • Provides attachments for muscles and ligaments

* Easily fractured during falls and can take a while to heal

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24
Q

Intervertebral discs function

A

—> • Permit some movement between vertebrae & act as a shock absorber

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25
Q

Intervertebral discs structure

A
  • Symphyses (secondary cartilaginous joints)
  • Account for 20-25% of the length of the vertebral column
  • Thicker anteriorly in cervical and lumbar regions – produce secondary lordosis curvature of column
  • mostly made of water
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26
Q

Intervertebral discs

• Consist of two regions:

A
  • nucleus pulposus (central)

* annulus fibrosus (peripheral)

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27
Q

Annulus fibrosus

A

—> strong ring like, made of type 1 (and 2 ) collagen
Made from concentric lamellae (layers) of fibrocartilage
• Fibers in adjacent lamella cross each other obliquely in opposite directions = strength
• Thinner posteriorly
• Avascular and Aneural = less sensation centrally
• Decreasing vascularized centrally
• Only outer third receives sensory innervation

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28
Q

Nucleus pulposus (remanant of notocord)

A

—> • Gelatinous, semifluid made of Type 2 (&1) Collagen
• Act as shock absorber
• Disc Height changes during day & change becomes permanent with age
• Posteriorly located with age
• Disc prolapse
• Avascular – nutrients by diffusion

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29
Q

Function of Ligaments of the vertebral column

A

—>Provide stability
Spinous processes with interspinous ligaments between them
Stability and inflexions

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30
Q

5 Ligaments of the vertebral column

A 
Anterior longitudinal ligament 
Posterior longitudinal ligament
Ligmentum flavum (L.flavus, yellow) 
Interspinous ligaments 
Supraspinous ligaments
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31
Q

Anterior longitudinal ligament

Structure

A

• Strong, broad
Extends from anterior tubercle of atlas to sacrum
• Thickest anteriorly, but extends to IV foramen
• Blends with periosteum of vertebral bodies - strong

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32
Q

Anterior longitudinal ligament

Function

A
  • Mobile over intervertebral discs
  • Prevents hyperextension
  • only ligament that limits extension of the spine
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33
Q

Posterior longitudinal ligament

Structure

A

—> even though it is long Narrower & weaker than ALL
• Body of axis (C2) to sacrum
• Within vertebral canal
• Attached more to IV discs, less to vertebral bodies

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34
Q

Posterior longitudinal ligament

Function

A

• Weakly prevents hyperflexion
—> Prevents or redirects posterior herniation of nucleus pulposus (leading to paracentral disc prolapses)
• Well provided with nociceptive (pain) nerve ending

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35
Q

Ligmentum flavum (L.flavus, yellow)

Structure

A

Posteriorly in spinal canal
• Pale yellow bands of elastic tissue - a lot of elastin
• Extend from laminae above to lamina below

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36
Q

Ligmentum flavum (L.flavus, yellow)

Function

A
  • Strong = Resist separation of lamina = stability
  • limit abrupt flexion (and injury to IV discs)
  • (elastic) Help straightening of column after flexing
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37
Q

Interspinpous ligaments

Structure

A

–> run obliquely with spinous processes
• Relatively weak ligaments (often membranous)
• From root to apex of each adjoining spinous processes
• Well developed only in lumbar region

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38
Q

Interspinpous ligaments

Function

A
  • stability in flexion

* Fuse with supraspinous ligament

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39
Q

Supraspinous ligaments

Structure

A

–> supra means above – runs above/ between spinous processes
• Strong cord like bands of white fibrous tissue
• Connect tips of spinous processes from C7 to the sacrum
• Merge superiorly with nuchal ligament (back of neck)

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40
Q

Supraspinous ligaments

Function

A

• Lax in extension
• Tight in flexion (mechanical support for vertebral column)
The weak interspinous and strong supraspinous ligaments unite adjoining spinous process = merge together

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41
Q

Curvature of vertebral column

A
  • Foetal spine is C-shaped
  • Thoracic and Sacral Kyphoses (sing Kyphosis) are primary curvatures (in adult) – concave anteriorly - similar to foetal spine
  • Cervical and lumbar lordoses (sing lordosis) are secondary curvatures (diff from foetal spine)– concave posteriorly - result from extension
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42
Q

C shaped spine

A

• Foetal spine is C-shaped

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43
Q

Kyphosis

A

• Thoracic and Sacral Kyphoses (sing Kyphosis) are primary curvatures (in adult) – concave anteriorly - similar to foetal spine

)

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44
Q

Lordosis

A

• Cervical and lumbar lordoses (sing lordosis) are secondary curvatures (diff from foetal spine)– concave posteriorly - result from extension

(

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45
Q

How spine becomes lordotic

A

– Begin late foetal period but not obvious until 1st year
- eg head extension while prone/ sitting (neck)
– and upright standing/ walking (lumbar)

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46
Q

Weight and spine curvature

A

• Carrying extra weight (inc obesity in abdomen) increases curvatures – resisted by contractions of muscle groups (muscle spasm)-> pain

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47
Q

Movements of lumbar spine

A

—> flexion and extension, lateral flexion and extension, rotation (left and right mainly from thoracic region)
• Range of movement limited by IV discs, facet joints, ligaments, back muscles, bulk of surrounding tissue
• Movement produced by back muscles, gravity and anterolateral abdominal muscles [importance of strengthening to avoid backpain]
• Weight transmitted 80% through vertebral bodies and 20% through facet joints

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48
Q

Spinal cord

Overall structure

A

• Begins as continuation of medulla oblongata = Ends as conus medullaris at L1 or L2 (but can T12 - L3)
• Enlarges in relationship to innervation of limbs, nerves going in and out
– cervical enlargement (C4-T1)
– lumbosacral enlargement (T11-S1)
• Long roots from inferior segments (lumbar / sacral / coccygeal nerves) descend in cauda equina (L. horse tail) to exit at their respective foramina

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49
Q

Spinal cord - 2 enlargements

A

• Enlarges in relationship to innervation of limbs, nerves going in and out
– cervical enlargement (C4-T1)
– lumbosacral enlargement (T11-S1)

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50
Q

Filum terminale

A

—> Vestigial remnant of the caudal part of the spinal cord
• Arises from conus medularis & attaches to dorsum of coccyx

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51
Q

Filum terminale function

A

• Provides support to inferior end of spinal cord & meninges

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52
Q

3 parts of spinal meninges

A

• Spinal meninges = dura, arachnoid and pia mater (D.A.P.) remember order– surround, support, protect Spinal cord and roots (inc cauda equina)

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53
Q

Spinal cord in embryos

A

• spinal cord occupies whole length of vertebral canal
• Cord segments lie approximately at vertebral level of same number
– i.e. spinal nerves pass laterally to exit at corresponding IV foramen
-L1 cord corresponds with L1 vertebrae

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54
Q

Spinal cord and foetal development

A
  • During foetal development the vertebral column grows faster than spinal cord - progressive obliquity of the spinal n. roots from cervical to lumbar
    • Spinal nerves pass laterally to exit and intervertebral foramen
    • Lumber and sacral, nerves are much longer and oblique, vertical before they exit = cauda equina pattern
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55
Q

Spinal dura

A

• Tough mainly fibrous tissue
• Continuous with cranial dura
• Separated from periosteum (of bone) and ligaments by epidural space (outside the dura between bone and dura0
– contains epidural fat and small veins = can be used for epidural anesthesia n space between periosteum and dura (epidural space)
(Adheres to foramen magnum and anchored inferiorly to coccyx by filum terminal)

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56
Q

Dural root sheath

A

• Tapering lateral extensions of spinal dura surround each pair of (anterior and posterior) nerve roots
• Blends with epineurium (connective tissue covering spinal nerves) and adheres to periosteum surrounding each opening
Injecting = numbing some of these nerves and not the whole spinal cord

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57
Q

Spinal arachnoid

A
  • Arachnoid: membrane, lines dural sac & root sheaths
  • Not attached to dura, but held against it (by CSF pressure) = potential pathological “subdural space”
  • Encloses CSF (subarachnoid space)
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58
Q

Spinal pia

A
  • Pia: thin membrane

* Follows surface of spinal cord and roots of spinal nerves

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59
Q

Layers of spinal meninges

A

Dura (outside dura is epidural space)
Arachnoid (between dura and arachnoid = potential space = subdural space)
Sub arachnoid space deep to arachnoid (CSF fluid in here that bathes nerves)
Pia

60
Q

Lumbar puncture landmarks (or spinal anaesthesia)

A
  • Surpacristal plane passes through level of the transverse process of L4 (or iliac crest) ; intervertebral spaces can be counted from here
  • L4-5 space; L3-4 or L5-S1 space also safe in adults = where you are aiming to inject
  • Needle inserted into the subarachnoid space (lumbar cistern)
    • Lean over or chair or getpatient to get their knees up while sitting on chair
61
Q

Trabeculae and ligaments

A

• Arachnoid trabeculae: delicate strands connect Arachnoid to Pia
• Spinal cord suspended in dural sac by filum terminale and R & L denticulate ligaments = fibrous sheet of pia, attach to inner arachnoid
– from lateral surface of spinal cord (between ant & post nerve roots)
– Sawtooth like appearance due to nerves around them, help suspend spinal cord in dural sac (L denticulus, small tooth)

62
Q

Spinal nerves - how they exit

A

• (7 Cervical vertebrae but 8 nerves)
• C1-C7 exit above corresponding vertebrae
• Spinal nerve C8 exits between vertebrae C7 and T1 (as there is no C8 vertebrae
• T1-L5 exit below corresponding vertebrae
• S1-S4 exit via sacral foramina
S5 and Co1 exit via sacral hiatus (posterior

63
Q

Arteries supplying spinal cord

A

• Longitudinal anterior and 2 paired posterior spinal arteries (usually from vertebral arteries) = clinical significance in spinal stroke

  • Ant & post segmental medullary arteries – mainly around cervical and lumbosacral enlargements – Great anterior segmental medullary artery = on Left in 65% people
  • Posterior and anterior radicular arteries run along & supply nerve roots (L radix, root)
64
Q

Nerves structure (EpiPeEn)

A

—> epineurium (outside), perineurium and epineurium
• Axon and myelin sheath surrounded by endoneurium
• A bundle of nerve fibres, fascicle, surrounded by perineurium
• The bundles/ fascicles surrounded by epineurium
• [mesoneurium or paraneurium – loose areolar tissue surrounding, contains blood vessels ]

65
Q

Spinal nerve roots - formation

A

• Arise as rootlets, converge to form 2 nerve roots

66
Q

• Dorsal (posterior) roots

A

• Dorsal (posterior) roots contain afferent / sensory nerve fibers from cell bodies in spinal cord or dorsal root ganglion – extend peripherally to sensory endings and centrally to posterior horn of spinal cord grey matter

67
Q

• Ventral (anterior) roots

A

• Ventral (anterior) roots contain efferent / motor nerve fibres from nerve cell bodies in the anterior horn of spinal cord grey matter to effector organs peripherally and autonomic nerve fibers

68
Q

Spinal nerve roots → rami

A
  • Posterior and anterior nerve roots unite – in or just proximal to IV foramen – to form mixed (both motor and sensory) spinal nerve
  • This immediately divide into 2 rami (L. branches) – also mixed - dorsal ramus and ventral ramus
    • Rami means branch
69
Q

Rami

A

Rami means branch

  • Spinal nerves also give off a meningeal branch – Re-enters spinal canal through intervertebral foramen
  • Rami communicantes: components of autonomic system
70
Q

Posterior / dorsal rami

A

• Posterior / dorsal rami: supply joints of vertebral column, deep muscles and skin of the back

71
Q

Anterior / ventral rami

A

• Anterior / ventral rami: supply muscles and skin on anterior & lateral trunk & limbs

72
Q

Motor and sensory nerves

A

—> motor and sensory terms are relative, not completely motor or sensory

* Motor nerves to muscles of trunk & limbs contain 40% sensory fibres (pain & proprioception) * Cutaneous sensory nerves contain motor fibres – sweat glands and smooth muscle of blood vessels and hair follicles
73
Q

Dermatomes

A

—> Unilateral area of skin supplied by single spinal nerve = Dermatome

74
Q

Myotome

A

• Myotome = (Unilateral mass of muscle supplied by single spinal nerve = myotome)

75
Q

Dermatomemaps

A
  • Dermatome maps developed – innervation of skin by specific spinal nerves, areas that correspond with spinal nerves
  • Lesion of single spinal nerve (or dorsal root) would rarely result in numbness of skin marked – adjacent nerves overlap almost completely BUT it is usefully clinically
76
Q

Dorsal rami

A

—> Supply skin of back in a segmental manner = tidy narrow strips
• Divide into medial and lateral branches
• Supply skin of back in ‘tidy’ segmental manner - narrow strips in line with intervertebral foramen

77
Q

Anterior rami

A

In trunk maps similar • In Limbs more complicated
• Multiple anterior rami contribute to plexus formation
• Multiple peripheral nerves arise from the plexus
• A spinal nerve can contribute to more than one peripheral nerve (nerves coming out of cervical spine)
• Also most peripheral nerves (from the plexus) contain fibres from multiple spinal nerves
—> peripheral nerves have fibres from multiple spinal nerves

78
Q

Herpes Zoster (shingles)

A

—-> Viral infection, generally affects the skin of a single dermatome = caused by Reactivation of Varicella zoster virus (chickenpox)
• Virus travels through a cutaneous nerve and remains dormant in a dorsal root ganglion after chickenpox
• When host is ‘immunosuppressed’(just a bit ill) , VZV virus reactivates and travels through peripheral nerve to skin of a single dermatome
• Can be quite painful, there is a vaccine for this that reduces their chance and pain of symptoms

79
Q

Peripheral nerve territories – maps

A

—> what sensory loss there is if a patient gets a cut to their nerves (damage to peripheral nerves)
• Mapping cutaneous distribution of peripheral nerves gives a different map in limbs
• These are not dermatomes

80
Q

Motor unit

A

(A motor unit is a motor neuron and the skeletal muscle fibres it innervates)
⇒ 1 spinal nerve (e.g. C6) contains the neurons of many motor units

81
Q

Myotomes upper limb MEMORISE

A
  • C5: shoulder abduction and external rotation plus weak contribution to elbow flexion
    • C6: elbow flexion / wrist extension / supination /internal rotation of shoulder
    • C7: elbow extension / wrist flexion / pronation / weak contribution to finger flexion and extension
    • C8: finger flexion / finger extension / thumb extension / wrist ulnar deviation
    • T1: finger abduction and adduction
82
Q

C5

A

shoulder abduction and external rotation plus weak contribution to elbow flexion

83
Q

C6

A

elbow flexion / wrist extension / supination /internal rotation of shoulder

84
Q

C7

A

elbow extension / wrist flexion / pronation / weak contribution to finger flexion and extension

85
Q

C8

A

finger flexion / finger extension / thumb extension / wrist ulnar deviation

86
Q

T1

A

finger abduction and adduction

87
Q

Myotomes lower limb MEMORISE

A
  • L2: hip flexion
    • L3: knee extension and hip adduction
    • L4: ankle dorsiflexion
    • L5: great toe extension /ankle inversion / hip abduction
    • S1: ankle plantar-flexion/ankle eversion/ hip extension (or L5)
    • S2: knee flexion (some sources say S1 for this) /great toe flexion
88
Q

L2

A

hip flexion

89
Q

L3

A

knee extension and hip adduction

90
Q

L4

A

ankle dorsiflexion

91
Q

L5

A

great toe extension /ankle inversion / hip abduction

92
Q

S1

A

ankle plantar-flexion/ankle eversion/ hip extension (or L5)

93
Q

S2

A

knee flexion (some sources say S1 for this) /great toe flexion

94
Q

Hilton’s law

A

—> nerve supplying the muscles working across a joint also innervate and supply that joint and the skin overlying the muscle
e.g.
• Myotome for knee extension is L3
• Dermatome overlying the anterior knee is L3
• Assessing spinal cord injury

95
Q

Peripheral nerve injury

A

Femoral nerve injury = paralysis in muscle supplied by femoral nerve.

96
Q

3 abnormal curvatures of the spine

A

scoliotic spine, curve from side to side
kyphosis, spine bends forward
lordosis, lumbar sacral spine

97
Q

Physiological curves - pregnancy

A

Physiological curves that will return to normal

* Head shifts forward, chin tucks in back = cervical lordosis increase
* Enlarged breast and belly = accentuates thoracic kyphosis and lumbar lordosis 
* Increase anterior tilt of pelvies = maintain centre of gravity
98
Q

Purpose of spine

A

• Resistance to axial loading forces

  • Kyphotic and lordotic balanced sagittal plane curves
  • Increased mass of each vertebra from C1 (head) - sacrum

• Elasticity (flexible)

  • Alternating kyphotic and lordotic curves
  • Multiple motion segments – seen with vertebrae
99
Q

7 Lumbar spine disorders

A
  • Mechanical back pain
  • Degenerative back pain
  • Radicular pain (Prolapsed intervertebral disc, Sciatica)
  • Neurological claudication (Spinal stenosis)
  • Spondylolisthesis
  • Tumours
  • Infection
100
Q

Lumbar back pain

A
  • Affects 50-80% of the population in a lifetime
  • Second only to respiratory infection as a cause of visits to the doctor
  • Most – more than 80% of the population have episodes of low back pain which lasts more than 24 hours
  • About 50% experience episodes lasting over 4 weeks
101
Q

Mechanical back pain

A
  • Occurs when the spine is loaded
    • occuring with activities such as lifting and prolonged sitting/standing
    • facet degeneration, instability in spine can cause the symptoms
  • Worse with exercise
    • Ususally Muscular (usually stiff with difficulty in bending)
102
Q

Risk factors – to mechanical back pain

A
  • Obesity
  • Unhealthy sedentary lifestyle
  • Lifting, vibration
  • Poor core musculature

• Mental health

  • Benefits – people receiving financial benefits
  • Accident
  • Fears
  • Job
  • Relationship
103
Q

Mechanical back pain

Treatment

A

Intermittent
• Resolves spontaneously
• Might need physiotherapy – to improve mobility
• Further investigation if diagnosis is unclear
• Usually a diagnosis of exclusion

104
Q

Degenerative back pain

A
  • Nucleus pulposus (in centre of discs) dehydrates with age
  • Loss of disc height causing disc bulging
  • Load stress on the intervertebral disc leads to the development of marginal osteophytes (protrusions of bone) on the adjacent vertebral endplates – Syndesmophytes
  • Increased load on the facet joints – Facet joint arthritis
  • Decreased size of the intervertebral and vertebral foraminae can cause cord compression and compression of the spinal nerve roots
105
Q

What is seen in X rays of spine in osteroarthritic patient

A
  • Narrow disc spaces
    • Little osteophytes
    • Desicated dark discs in MRI
    • Adjacent changes in end places
106
Q

Hernation of intervertebral Disc (‘slipped disc’)

A
  • Pain occurs due to the herniated disc material pressing on the spinal nerve
  • Commonly occurs in the 4th and 5th decades
  • 3:1 male to female ratio = more common in males
  • Approximately 5% become symptomatic
  • 90% resolve within 3 months with non operative care
107
Q

Herniated discs

  • cause
A

—> result of Recurrent torsional strain leading to tears of the annulus fibrosus and herniation of the nucleus pulposus

108
Q

3 stages of disc hernicition

A
  • Protrusion/Prolapse of the disc causing eccentric bulging with an intact annulus (as herniation begins to occur)
    • Prolapse = as bulge increases, annulus intact slightly thinner
  • Extrusion – the disc material herniates through the annulus but is still part of the body of the disc
  • Sequestered (free) fragment – the disc material is herniated and no longer continuous with the disc space
109
Q

What can be seen on Images showing herniated disc pathology

A
  • Annulus with nucleus pulposus = extruded into foramina region and pressing on nerve root
    • Disc has protruded
    • Disruption between sequestered part of disc and rest of nucleus
    • Nerve root pressing
110
Q

Most commons sites for slip discs (disc herniation) – nerve roots

A
  • The most common sites for a ‘slipped disc’ are L4/L5 and L5/S1
  • The nerve root exits from BELOW its respective vertebra
  • nevre root is Most vulnerable where it crosses the disc (paracentral – 96%) and where it exits the spinal canal in the neural foramen (lateral)
  • 2% occur centrally
111
Q

Radicular pain – sciatica

A

• Pain caused by irritation or compression of one or more of the nerve roots contributing to the sciatic nerve (L4-S3)

* The pain typically starts in the back and buttock radiating to the dermatome of the nerve root that has been affected
* Take good clinical hisotry and examiantion to determine affected nerve root
112
Q

Radicular pain – sciatica

Cause

A

• Pain caused by irritation or compression of one or more of the nerve roots contributing to the sciatic nerve (L4-S3)

113
Q

Distribution of nerves

A
  • L4 - Anterior thigh, anterior knee and medial leg
    • L5 – Lateral thigh, lateral calf, dorsum of foot
    • S1 – Posterior thigh, posterior calf, sole of foot
114
Q

What does L4 supply

A

• L4 - Anterior thigh, anterior knee and medial leg

115
Q

What does L5 supply

A

• L5 – Lateral thigh, lateral calf, dorsum of foot

116
Q

What does S1 supply

A

• S1 – Posterior thigh, posterior calf, sole of foot

117
Q

6 common disc pathologies

A
  • Normal disc
    • Degenerative disc
    • Bulging disc = posterior herniation
    • Herniated disc
    • thinning disc
    • Disc degeneration with osteophyte formation
118
Q

Cauda equina syndroma

A

• Group of symptoms that result from terminal spine root compression in the lumbosacral region

Medical emergency

119
Q

Cauda equina syndrome causes

A

—> Space occupying lesion within the lumbosacral canal
- Disc herniation (most common)
- Spinal stenosis – secondary to arthritis
- Tumours
- Trauma
– fracture / dislocation
- Spinal epidural haematoma
- Spinal infection / abscess
- Late stage ankylosing spondylitis

120
Q

Cause equina presentation

A

—> most common presenting symptoms

  • Back pain
  • Unilateral / Bilateral leg pain
  • Faecal and urinary incontinence
  • Painless urinary retention
  • Saddle anaesthesia
  • Erectile dysfunction
  • Lower extremity sensorimotor changes
121
Q

Cauda Equina red flag signs

A 
Bilateral leg pain 
• Faecal and urinary incontinence 
• Painless urinary retention 
• Saddle anaesthesia 
• Erectile dysfunction
122
Q

Cauda equina

What is seen in imaging

A
  • Extruded disc centrally
    • Compressing the spinal cord
    • Seen more clearly in MRI
    • Nerve roots are compressed
    • Spinal canal = narrow
123
Q

Cauda equina – treatment

A

Surgical decompression within 48 hours of the onset of sphincter symptoms

124
Q

Implication of misdiagnosis and treatment of cauda equina syndrome

A

—> Serious and life changing consequences

  • Chronic neuropathic pain
  • Having to perform intermittent self-catheterisation to pass urine
  • Fecal incontinence requiring manual rectal evacuation
  • Loss of sensation and lower limb weakness
  • Impotence
125
Q

Spondylolishtesis

A

—> another lumbar spine disorder = less common

• Displacement of one vertebra over the one below.

Most commonly anterior.

126
Q

Spondylolishtesis - various types

A
  • Congenital /dyplastic (facet joint instability)
  • Isthmic (Pars interarticularis defect)
  • Degenerative
  • Traumatic
  • Pathological
    – infection / malignancy
127
Q

Dysplastic spondylolisthesis

A

—> Abnormality in the facet joint at L5/S1 causing a gradual slip
L5 moves forward over S1 which stayed behind

128
Q

Isthmic spondylolisthesis & spondylolysis

A
  • Abnormality in the pars interarticularis – defect / fracture
  • More common in L5/S1
  • Back pain in adolescents
  • Gymnasts and fast bowlers
129
Q

Spondylolisthesis Scotty dog sign

A
  • Nsoe = transverse process
    • Eye = pedicle
    • Neck = pars interacrticularis
    • Defect would be over the dog collar
130
Q

Degenerative spondylolisthesis

A
  • More common in women possibly due to ligamentous laxity related to hormonal changes
  • No pars defect
  • More common in L4/L5
  • Facet joint arthritis

Slip, L4 slids anteriorly over L5

131
Q

Iatrogenic and pathological Spondyloesthesis

A
  • Iatrogenic as a result of removing too much lamina and facet joint at surgery
  • Pathological – tumour / infection affecting the neural arch
132
Q

Spondyloesthesis – symtpoms

A

• May be associated with vertebral column instability ‘

Symptoms:-
• Most patients complain of lower back pain of various degrees
• Radicular pain
• Neurogenic claudication

133
Q

Grading of spondylolisthesis

A 
Grade 1 (minor slip)
Grade 4 (more than 75% anterior of vertrbal slipage of vertebr\e
134
Q

Neurogenic claudication - symptoms

A
  • Also known as pseudoclaudication
  • Symptom
  • Pain and / or pins and needles in the legs on prolonged standing and walking related to the sciatic nerve distribution
  • Patient feels pain / cramps in the lower limbs causing a limp (claudigo)
135
Q

Neurogenic claudication

What is it

A

Age related
• Disc bulge
• Facet joint hypertrophy (OA)
• Ligamentum flavum hypertrophy

Narrowing of spinal canal causing stenosis = narrowing of joint space in spinal canal

  • Compression of the spinal nerves as they emerge from the spinal cord leading to venous engorgement of the nerve roots on exercise.
  • Results in reduced arterial inflow and transient ischaemia - Pain and / or paraesthesia
136
Q

Spinal stenosis symptoms

A 
• Uni / bilateral leg pain 
• Typically relieved by: 
- Rest 
- Change in position 
- Flexion at the waist

Common for people to sit and bend over and rest

137
Q

Neurogeneic claudication - movements

A

Movements involving flexion at the waist such as cycling, pushing a trolley or climbing stairs are usually well tolerated.
• As they tend to open the spinal canal

138
Q

Quadraplegia

A

Paralysis from neck down

  • trunk legs and arms
  • affects all 4 limbs
139
Q

Paraplegia

A

Loss of movement and sensation of lower limos

140
Q

Phrenic nerve

A

Anterior rami - c3 → c5

141
Q

What level does ankle jerk test

A

S1

142
Q

4 factors that contribute to stability of vertebral column

A
  • Ligaments
  • intravertebral discs
  • size of vertebral body/orientation
  • muscles
143
Q

What is the cauda equina

A
  • Continution of nerve roots in lumbar and sacral region like a horse tail
  • ability to move legs and bladder sensation
144
Q

Supracristal plane

A

Passes through tip of L4 spinous process and l4 / l5

145
Q

Read worksheet D surface anatomy

A

Y1 TP2 Musculoskeletal System (10 decks)

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