15. Back problems - Robson Flashcards
What is the order of the vertebrae in the vertebral column?
Cervical
Thoracic
Lumbar
Sacral
What is a kyphosis curve?
Excessive outward curvature of the spine
What is a lordosis curve?
Excessive inward curvature of the spine
What are the primary curves in the vertebral column?
Kyphoses - thoracic and sacral
What are the secondary curves in the vertebral column?
Lordoses - cervical and lumbar
Which curves of the vertebral column are more movable?
The secondary curve
Lordoses - cervical and lumbar
Why are the kyphoses less movable?
Thoracic - ribs holding them in place
Sacrum - fused so not as much movement
What is an abnormal curvature in terms of the vertebral column?
An increase or a decrease in one of the normal curves OR a new curve (scoliosis)
What is meant by scoliosis?
The presence of a new curve - if the vertebae move laterally to each other
When might an abnormal curve arise?
If any of the 24 vertebrae develop abnormally
What are common causes of an increased thoracic kyphoses?
Osteoporosis
Erosion
Fracture to the anterior part of the vertebrae
How will an increased thoracic kyphosis present?
Humpback/hunchback
What happens during an osteoporosis kyphosis?
There is a reduced trabecular bone and so there is compression of the vertebra - get a wedged shaped vertebra
This causes the vertebra to move anteriorly
What typically happens alongside an increased thoracic kyphosis?
There will usually be a compensatory cervical lordosis to keep the head looking up and forwards
How can you treat a osteoporosis kyphosis?
Want to reinflate the deflated vertebra via ‘vertebral augmentation’ - inject bone cement which will push up the cortical bone of the vertebra
What is vertebral augmentation?
Treatment for osteoporosis in the vertebrae causing them to wedge
Inject bone cement into the vertebra to push up the cortical bone
What is the main advantage of vertebral augmentation on the spinal cord
Increases the space of the IV foramina - reduced compression of the spinal cord
How can you tell if a vertebra is osteoporotic from a scan?
Look at the posterior, central and anterior height - if they are drastically decreasing - wedging is occurring
What is adolescent kyphosis/Sheuermann’s disease?
Disease of the epiphyseal growth plates or vertebrae (usually thoracic)
Wedging of the bone
Who is affected by adolescent kyphosis/Sheuermann’s disease?
Adolescents all the through adulthood
What is the prevalence of adolescent kyphosis/Sheuermann’s disease in children?
Affected 1% of children
What are the symptoms of adolescent kyphosis/Sheuermann’s disease?
Pain
Difficulty breathing
How can adolescent kyphosis/Sheuermann’s disease be recognised in a scan?
Schmall’s nodes - these are depressions in the centre of the vertebra at the nucleus propulses of the IV disk
What is the treatment for adolescent kyphosis/Sheuermann’s disease?
Wear a brace to help straighten and correct the curvature
Ensure future growth is in the correct alignment
Two muscular causes of lumbar lordosis are?
Weakened trunk muscles
Weakened hip flexors
What happens to the body weight during lumbar lordosis?
The body weight shifts anteriorly
How is the shift in body weight during lumbar lordosis compensated for and what affected does this have on the lordosis?
Via an increased pelvic tilt (anterior pelvic tilt) and this further increases the lumbar lordosis
When does a lumbar lordosis commonly occur?
During late pregnancy or obesity
What is lumbar lordosis also commonly known as?
Hollow-back, sway-back
What are the symptoms of lumbar lordosis?
Back ache
Sciatica - symptoms along dermatomal distribution of the sciatic nerve
What is the dermatomal distribution of the sciatic nerve?
Around L5 and S1 - lower back and back of leg
What structures can lumbar lordosis cause damage to?
IV discs - stretched anteriorly and compressed posteriorly
Impinge on nerve roots passing through IV foramina
What is the role of the psoas in lumbar lordosis?
In some individuals, psoas dysfunction e.g. shortened or weakened psoas can push the hip further into extension - muscle imbalance will result in lumbar lordosis
What is flat back syndrome?
This is where the is a backward and posterior pelvic tilt resulting in a flat back - very flat lumbar lordosis
What is flat back syndrome usually a result of?
Usually due to tight paraspinal muscles between the ribs
What is the other presentation of flat back syndrome other than a flat back?
Usually will have a slight bend in their knees due to bent thighs
What is scoliosis?
Development of a new curve
The vertebrae move laterally and rotate on top of one another - no longer aligned as they should be
What is the prevalence of scoliosis?
3% of the population
Who is scoliosis most prevalent in?
Girls around the age of puberty
What is one possible cause of scoliosis?
May be linked to hormonal changes of the ligaments - causes softening of the ligaments
In the majority of the population, how does scoliosis present?
In the majority of these individuals - scoliosis is present but causes no symptoms
What is the most common cause of scoliosis?
What are some other causes?
Majority of these are idiopathic
Developmental defects
Asymmetric muscle strength
Poor posture
What vertebral region is scoliosis usually present in?
In the thoracic-lumbar regions - mostly in the thoracic and then a compensatory curve in the lumbar region
What is the impact of scoliosis on the scapulae?
Causes one scapula to be higher than the other
What is the treatment for scoliosis?
Curve less than 20 degrees - leave it
Curve between 20-40 degrees - wear a brace
Curve greater than 50 degrees - surgical options
What are the surgical treatment options for scoliosis?
Vertebral fusion (causes flat back so not used much now) Harrington rods - on either side of the vertebrae and inserted into the bodies - act as a rigid support
What are osteophytes in the vertebral body known as?
Syndesmophytes
What is a syndesmophyte?
This is an osteophyte that is present in the vertebral body - change in name depending on location
What is the location of an ‘osteophyte’?
Osteophytes grow around the synovial joints
How can you recognised degenerative spine disorders on a scan?
Syndesmophytes Loss of disc height Loss or increase in curves Spinal stenosis Ossification of vertebral ligaments
What is spinal stenosis?
Abnormal narrowing (stenosis) of the spinal canal
What are the two components of the IV disc?
Annulus fibrosus - outer
Nucleus pulposus - central
What is the annulus fibrosus composed of?
Alternating layers of collagen type 1
What is the innervation to the annulus fibrosus?
The outer third is innervated
What happens to the annulus fibrosus as we age?
Becomes more brittle and not as resilient - tears and damages - results in a loss of height
What is the nucleus pulposus composed of?
70-90% water
Proteoglycans
What is the purpose of the nucleus pulposus?
Acts to absorb shock
What happens to the nucleus pulposus with increasing age?
Dries out and becomes less resilient at absorbing shock
What is the innervation of the nucleus pulposus?
Central nucleus pulposus has no innervation - is completely dependent on the outer annulus fibrosus
Which out of the annulus fibrosis and the nucleus pulposus is avascular?
Nucleus pulposus - remember this is completely dependent on the outer annulus fibrosus
At what age does the annulus fibrosus start to dry out?
At the age of 30
Which of the vertebrae dry out faster than the others and why?
Lumbar vertebrae - because they are the largest in size
Where along the vertebral column does a herniation/prolapse occur?
Can occur along the whole length of the column
Where along the vertebral column does a herniation/prolapse most commonly occur?
The IV disc between L4 and L5 or L5 and S1
In which direction does a disc herniation/prolapse generally occur and why?
Posteriorly because the anterior longitudinal ligament is very strong and broad running down the whole of the anterior aspect of the column
What is the adverse effect associated with IV disc herniation/prolapse?
Nerve root compression - radiculopathy so pain and irritation - OR spinal nerve compression
What is cauda equina syndrome?
This is a more serious form of a herniated IV disc
The disc herniates posteriorly and also slightly to the side of the spinal nerve root - hits the cauda equina - compression of multiple nerve roots - serious neurological condition
What is the cauda equina?
Series of nerve roots that come down to exit through the sacrum
What IV herniation is associated with the cauda equina?
Cauda equina syndrome
Which nerves are affected in cadua equina syndrome? x4
Sciatic
Obturator
Femoral
Pudendal
What are the clinical presentations of cauda equina syndrome?
Low back pain
Sciatica - unilateral or bilateral
Bowel and bladder disturbances
Reduced or absent lower extremity reflexes
What are the two treatment options for cauda equina syndrome?
Discetomy
Laminectomy
What is a discetomy?
Removal of the IV disk - replaced with a bone graft
What is a laminectomy?
Remove the lamina of the spinous process
What is a burst fracture and how does this relate to cauda equina syndrome?
The vertebra bursts - if this then moves posteriorly then can result in cauda equina syndrome
What is the later impact of a burst fracture on the IV disc?
Causes a fracture haematoma and blood can enter into the IV disc - haematoma within the disc
Results in degeneration and necrosis of the IV disc as there is nowhere for the blood to go
What is the conus meddalris?
This is the tapered, lower end of the spinal cord
What is the significance of syndesmocytes during ageing?
With increasing age, syndesmocytes develop around the margins of the vertebral body
What is the impact on the brain of syndesmocytes with age?
Syndesmocytes can block the blood flow through the vertebral/basilar artery when the head turns and can block the blood supply to the brain
What is diffuse idiopathic skeletal hyperostosis (DISH)?
Ossification of the anterior longitudinal ligament - often seen with osteoarthritis
At what age does DISH occur?
50-75 year olds
What is the cause of DISH?
Idiopathic
Do syndesmocytes occur with DISH?
Yes (in some instances no)
What is ankylosing spondylitis?
Chronic inflammatory disorder of the axial skeleton - affects the ligaments
Arthritis of the joints of the spine and sclerosis and ossification and akylosis of the ligaments
At what age does ankylosing spondylitis typically occur?
19-25 years
In which sex does ankylosing spondylitis typically occur?
Male
Is ankylosing spondylitis an autoimmune disease?
Yes
Which joint is commonly involved in ankylosing spondylitis?
Both sacroiliac joints
Is there a loss of disc space in ankylosing spondylitis?
No
What is the main structure that is at risk from ankylosing spondylitis?
The vertebral canal - because it has so many ligaments surrounding it
What is ‘ankylosis’?
Abnormal stiffening and immobility of a joint due to stiffening
What genetic variant is associated with ankylosing spondylitis?
HLA-B27
What is the association of HLA-B27 on the gut?
This impacts the gut flora - predisposes to a leaky gut (this could potentially result in the release of the inflammatory mediators to the joints)
What is subluxation?
Partial dislocation of the vertebral column
What is the most common place for subluxation and why?
The pivot joint between C1 and C2 due to erosion from pannus formation
What is eroded in the C2 vertebra during subluxation and what impact does this have?
The dens - become thinner and more unstable
Anterior pelvic tilt associated with which back condition?
Lumbar lordisis - anterior pelvic tilt froms as compensation
Posterior pelvic tilt associated with which back condition?
Flat back syndrome
Flat back syndrome relates to what tow muscle groups and how?
Tight hamstrings
Weak hip flexors
What is the radiological feature seen in ankylosing spondylitis?
Bamboo spine
The two joints involved in ankylosing spondylitis are?
Both sacroiliac joints
Most common subluxation of the vertebrae is where?
Atlantoaxial subluxation (C1 and C2)
