1. The Lumbar Spine Flashcards
The back
Posterior part of the trunk, inferior to neck and superior to gluteal region
Vertebral column
made up of vertebrae and intervertebral discs (approx. ¼ L)
Extends from cranium to apex of coccyx
What supports the weight anterior to the vertebral column
• -> Most weight is anterior to column - supported posteriorly by numerous and powerful muscles attached to strong spinous and transverse processes
4 Functions of the vertebral column
- 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
Structure of vertebral column
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
Mobile areas of vertebral column
Cervical and lumbar
Immobile area of vertebral column
Thoracic
Structure of typical vertebrae
• 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
Vertebral foramen
• 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
Vertebral body
—> 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
Intervertebral foramen
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
2 Transverse processes
- left and right
- project posterior-laterally
- arise from junction of pedicles and laminae
Provide attachment for deep muscles
1 Spinous process
• projects posteriorly & usually inferiorly
Provide attachment for deep muscles
4 Articular processes
- 2 superior and 2 inferior
- arise from junction of pedicles and laminae
- each with a articular facet
How many processes are there
7 Processes Arise from the Arch
- 1 Spinous process
- 2 Transverse processes
- 4 Articular processes
Zygapophysial joints
• (Zygapophysial joints) = Plane synovial joints, lined by hyaline cartilage
Facet joints - structure
- (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
Facet joints - function
- Allows flexion, extension and lateral flexion – but prohibits rotation
- Nerve supply and blocks – can be used to treat facet pain
What is the sacrum
—> inferior part of spine
Wedge shaped formed from 5 fused sacral vertebrae
• Articulates with L5 superiorly, ilium laterally, and coccyx inferiorly
Sacral canal
= continuation of vertebral canal
• contains bundle of spinal roots (inferior to L1) known as cauda equina (L. horsetail)
Sacrum- structure
- 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
Coccyx structure
—> Consists of 4 fused vertebrae
• Coccygeal vertebra 1 = Largest/ broadest, may remain separate from other 3
• Last 3 fuse to form beak like structure
Coccyx function
- Provides attachments for muscles and ligaments
* Easily fractured during falls and can take a while to heal
Intervertebral discs function
—> • Permit some movement between vertebrae & act as a shock absorber
Intervertebral discs structure
- 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
Intervertebral discs
• Consist of two regions:
- nucleus pulposus (central)
* annulus fibrosus (peripheral)
Annulus fibrosus
—> 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
Nucleus pulposus (remanant of notocord)
—> • 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
Function of Ligaments of the vertebral column
—>Provide stability
Spinous processes with interspinous ligaments between them
Stability and inflexions
5 Ligaments of the vertebral column
Anterior longitudinal ligament Posterior longitudinal ligament Ligmentum flavum (L.flavus, yellow) Interspinous ligaments Supraspinous ligaments
Anterior longitudinal ligament
Structure
• Strong, broad
Extends from anterior tubercle of atlas to sacrum
• Thickest anteriorly, but extends to IV foramen
• Blends with periosteum of vertebral bodies - strong
Anterior longitudinal ligament
Function
- Mobile over intervertebral discs
- Prevents hyperextension
- only ligament that limits extension of the spine
Posterior longitudinal ligament
Structure
—> 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
Posterior longitudinal ligament
Function
• Weakly prevents hyperflexion
—> Prevents or redirects posterior herniation of nucleus pulposus (leading to paracentral disc prolapses)
• Well provided with nociceptive (pain) nerve ending
Ligmentum flavum (L.flavus, yellow)
Structure
Posteriorly in spinal canal
• Pale yellow bands of elastic tissue - a lot of elastin
• Extend from laminae above to lamina below
Ligmentum flavum (L.flavus, yellow)
Function
- Strong = Resist separation of lamina = stability
- limit abrupt flexion (and injury to IV discs)
- (elastic) Help straightening of column after flexing
Interspinpous ligaments
Structure
–> 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
Interspinpous ligaments
Function
- stability in flexion
* Fuse with supraspinous ligament
Supraspinous ligaments
Structure
–> 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)
Supraspinous ligaments
Function
• Lax in extension
• Tight in flexion (mechanical support for vertebral column)
The weak interspinous and strong supraspinous ligaments unite adjoining spinous process = merge together
Curvature of vertebral column
- 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
C shaped spine
• Foetal spine is C-shaped
Kyphosis
• Thoracic and Sacral Kyphoses (sing Kyphosis) are primary curvatures (in adult) – concave anteriorly - similar to foetal spine
)
Lordosis
• Cervical and lumbar lordoses (sing lordosis) are secondary curvatures (diff from foetal spine)– concave posteriorly - result from extension
(
How spine becomes lordotic
– Begin late foetal period but not obvious until 1st year
- eg head extension while prone/ sitting (neck)
– and upright standing/ walking (lumbar)
Weight and spine curvature
• Carrying extra weight (inc obesity in abdomen) increases curvatures – resisted by contractions of muscle groups (muscle spasm)-> pain
Movements of lumbar spine
—> 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
Spinal cord
Overall structure
• 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
Spinal cord - 2 enlargements
• Enlarges in relationship to innervation of limbs, nerves going in and out
– cervical enlargement (C4-T1)
– lumbosacral enlargement (T11-S1)
Filum terminale
—> Vestigial remnant of the caudal part of the spinal cord
• Arises from conus medularis & attaches to dorsum of coccyx
Filum terminale function
• Provides support to inferior end of spinal cord & meninges
3 parts of spinal meninges
• Spinal meninges = dura, arachnoid and pia mater (D.A.P.) remember order– surround, support, protect Spinal cord and roots (inc cauda equina)
Spinal cord in embryos
• 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
Spinal cord and foetal development
- 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
Spinal dura
• 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)
Dural root sheath
• 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
Spinal arachnoid
- 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)
Spinal pia
- Pia: thin membrane
* Follows surface of spinal cord and roots of spinal nerves
Layers of spinal meninges
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
Lumbar puncture landmarks (or spinal anaesthesia)
- 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
Trabeculae and ligaments
• 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)
Spinal nerves - how they exit
• (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
Arteries supplying spinal cord
• 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)
Nerves structure (EpiPeEn)
—> 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 ]
Spinal nerve roots - formation
• Arise as rootlets, converge to form 2 nerve roots
• Dorsal (posterior) roots
• 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
• Ventral (anterior) roots
• 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
Spinal nerve roots → rami
- 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
Rami
Rami means branch
- Spinal nerves also give off a meningeal branch – Re-enters spinal canal through intervertebral foramen
- Rami communicantes: components of autonomic system
Posterior / dorsal rami
• Posterior / dorsal rami: supply joints of vertebral column, deep muscles and skin of the back
Anterior / ventral rami
• Anterior / ventral rami: supply muscles and skin on anterior & lateral trunk & limbs
Motor and sensory nerves
—> 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
Dermatomes
—> Unilateral area of skin supplied by single spinal nerve = Dermatome
Myotome
• Myotome = (Unilateral mass of muscle supplied by single spinal nerve = myotome)
Dermatomemaps
- 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
Dorsal rami
—> 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
Anterior rami
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
Herpes Zoster (shingles)
—-> 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
Peripheral nerve territories – maps
—> 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
Motor unit
(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
Myotomes upper limb MEMORISE
- 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
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
Myotomes lower limb MEMORISE
- 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
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
Hilton’s law
—> 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
Peripheral nerve injury
Femoral nerve injury = paralysis in muscle supplied by femoral nerve.
3 abnormal curvatures of the spine
scoliotic spine, curve from side to side
kyphosis, spine bends forward
lordosis, lumbar sacral spine
Physiological curves - pregnancy
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
Purpose of spine
• 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
7 Lumbar spine disorders
- Mechanical back pain
- Degenerative back pain
- Radicular pain (Prolapsed intervertebral disc, Sciatica)
- Neurological claudication (Spinal stenosis)
- Spondylolisthesis
- Tumours
- Infection
Lumbar back pain
- 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
Mechanical back pain
- 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)
Risk factors – to mechanical back pain
- Obesity
- Unhealthy sedentary lifestyle
- Lifting, vibration
- Poor core musculature
• Mental health
- Benefits – people receiving financial benefits
- Accident
- Fears
- Job
- Relationship
Mechanical back pain
Treatment
Intermittent
• Resolves spontaneously
• Might need physiotherapy – to improve mobility
• Further investigation if diagnosis is unclear
• Usually a diagnosis of exclusion
Degenerative back pain
- 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
What is seen in X rays of spine in osteroarthritic patient
- Narrow disc spaces
- Little osteophytes
- Desicated dark discs in MRI
- Adjacent changes in end places
Hernation of intervertebral Disc (‘slipped disc’)
- 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
Herniated discs
- cause
—> result of Recurrent torsional strain leading to tears of the annulus fibrosus and herniation of the nucleus pulposus
3 stages of disc hernicition
- 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
What can be seen on Images showing herniated disc pathology
- 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
Most commons sites for slip discs (disc herniation) – nerve roots
- 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
Radicular pain – sciatica
• 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
Radicular pain – sciatica
Cause
• Pain caused by irritation or compression of one or more of the nerve roots contributing to the sciatic nerve (L4-S3)
Distribution of nerves
- L4 - Anterior thigh, anterior knee and medial leg
- L5 – Lateral thigh, lateral calf, dorsum of foot
- S1 – Posterior thigh, posterior calf, sole of foot
What does L4 supply
• L4 - Anterior thigh, anterior knee and medial leg
What does L5 supply
• L5 – Lateral thigh, lateral calf, dorsum of foot
What does S1 supply
• S1 – Posterior thigh, posterior calf, sole of foot
6 common disc pathologies
- Normal disc
- Degenerative disc
- Bulging disc = posterior herniation
- Herniated disc
- thinning disc
- Disc degeneration with osteophyte formation
Cauda equina syndroma
• Group of symptoms that result from terminal spine root compression in the lumbosacral region
Medical emergency
Cauda equina syndrome causes
—> 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
Cause equina presentation
—> 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
Cauda Equina red flag signs
Bilateral leg pain • Faecal and urinary incontinence • Painless urinary retention • Saddle anaesthesia • Erectile dysfunction
Cauda equina
What is seen in imaging
- Extruded disc centrally
- Compressing the spinal cord
- Seen more clearly in MRI
- Nerve roots are compressed
- Spinal canal = narrow
Cauda equina – treatment
Surgical decompression within 48 hours of the onset of sphincter symptoms
Implication of misdiagnosis and treatment of cauda equina syndrome
—> 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
Spondylolishtesis
—> another lumbar spine disorder = less common
• Displacement of one vertebra over the one below.
Most commonly anterior.
Spondylolishtesis - various types
- Congenital /dyplastic (facet joint instability)
- Isthmic (Pars interarticularis defect)
- Degenerative
- Traumatic
- Pathological
– infection / malignancy
Dysplastic spondylolisthesis
—> Abnormality in the facet joint at L5/S1 causing a gradual slip
L5 moves forward over S1 which stayed behind
Isthmic spondylolisthesis & spondylolysis
- Abnormality in the pars interarticularis – defect / fracture
- More common in L5/S1
- Back pain in adolescents
- Gymnasts and fast bowlers
Spondylolisthesis Scotty dog sign
- Nsoe = transverse process
- Eye = pedicle
- Neck = pars interacrticularis
- Defect would be over the dog collar
Degenerative spondylolisthesis
- 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
Iatrogenic and pathological Spondyloesthesis
- Iatrogenic as a result of removing too much lamina and facet joint at surgery
- Pathological – tumour / infection affecting the neural arch
Spondyloesthesis – symtpoms
• May be associated with vertebral column instability ‘
Symptoms:-
• Most patients complain of lower back pain of various degrees
• Radicular pain
• Neurogenic claudication
Grading of spondylolisthesis
Grade 1 (minor slip) Grade 4 (more than 75% anterior of vertrbal slipage of vertebr\e
Neurogenic claudication - symptoms
- 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)
Neurogenic claudication
What is it
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
Spinal stenosis symptoms
• 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
Neurogeneic claudication - movements
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
Quadraplegia
Paralysis from neck down
- trunk legs and arms
- affects all 4 limbs
Paraplegia
Loss of movement and sensation of lower limos
Phrenic nerve
Anterior rami - c3 → c5
What level does ankle jerk test
S1
4 factors that contribute to stability of vertebral column
- Ligaments
- intravertebral discs
- size of vertebral body/orientation
- muscles
What is the cauda equina
- Continution of nerve roots in lumbar and sacral region like a horse tail
- ability to move legs and bladder sensation
Supracristal plane
Passes through tip of L4 spinous process and l4 / l5
Read worksheet D surface anatomy
