Back Anatomy and Management of a Slipped Disc Flashcards

1
Q

What is the function of the spine?

A
  • locomotor function
  • protects the spinal cord
  • spinal cord transmission of signals between brain and periphery
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2
Q

What is the spinal column made up of?

A
  • vertebrae
  • intervertebral discs
  • facet joints
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3
Q

How many spinal vertebrae are there?

A

24
- 7 cervical
- 12 thoracic
- 5 lumbar

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4
Q

What is the role of the intervertebral discs?

A

shock absorbers, allow segmentation & multi-directional movement

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5
Q

What is the role of the facet joints?

A

small synovial joints at posterior spinal column linking each vertebra

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6
Q

What are the key neurologial structures of the spine?

A
  • vertebrae
  • cauda equina
  • nerve roots
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7
Q

Where does the spinal cord end and corda equina start?

A

L2

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8
Q

Where do the nerve roots exit the spinal cord?

A

Bilaterally

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9
Q

What are the different movements of the spine?

A
  • flexion (bending forward)
  • extension (bend back)
  • rotation
  • lateral flexion (side bend)
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10
Q

What is chronic back pain?

A
  • back pain > 12 weeks
  • can be due to sedentary lifestyle
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11
Q

What is non-specific low back pain?

A

pain not due to any specific or underlying disease that can be found

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12
Q

What is mechanical low back pain?

A
  • Pain after abnormal stress and strain on the vertebral column
  • Reproduced or worse with movement
  • Better or not present at rest
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13
Q

What are the common causes of mechanical back pain?

A
  • Muscular tension (e.g. chronic poor posture, weak muscles)
  • Acute muscle sprain/spasm
  • Degenerative disc disease
  • Osteoarthritis of facet joints
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14
Q

What is nerve root pain (sciatica)?

A
  • pain radiating down one leg with or without neuralogical symptoms
  • may accompany mechanical back pain
  • often due to herniated disc compressing a lumbar nerve root
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15
Q

What determines the location of the pain caused by sciatica?

A

The level of the herniated disc

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16
Q

What is the natural history of a herniated disc?

A
  • most prevalent age 30-50
  • good outlook
  • normally spontaneous improvement but slower than lower back pain alone
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17
Q

What is the treatment for a herniated disc?

A
  • analgesia (NSAIDs)
  • physiotherapy to improve core strength and treat muscle spasms
  • inject nerve roots with local anaesthetic or glucocorticoid
  • surgery if neurological symptoms or symptoms persist
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18
Q

What are the serious causes of back pain?

A
  • tumour
  • infection
  • inflammatory spodnyloarthropathy
  • fracture
  • large disc prolapse
  • referred pain
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19
Q

What are the different infections which could cause back pain?

A
  • Discitis
  • Vertebral osteomyelitis
  • Paraspinal abcess
  • Microbiology: Staphylococcus, streptococcus, tuberculosis
20
Q

What are the different inflammatory spondyloarthropathies?

A
  • ankylosing spondylitis
  • psoriatic arthritis
  • inflammatory bowel disease (IBD)-associated
21
Q

What is the current NICE guidance for investigatinf back pain?

A
  • investigation usually not required if there are no red flags
  • do not routinely arrange imaging to diagnose non-specific back pain in primary care
  • arrange review of symptoms persist or worsen after 3-4 weeks and assess underlying causes

-

22
Q

What are the treatments for lower back pain with no red flags?

A
  • Time
  • Analgesia (NSAIDs e.g. ibuprofen, paracetamol, codeine)
  • AVOID bed rest: keep moving
  • Physiotherapy (Soft tissue work, Corrective exercises esp. core)
23
Q

Which blood tests are done for back pain?

A
  • ESR (myeloma, chronic inflammation, TB)
  • CRP (infection or inflammation)
  • FBC (anaemia in myeloma, chronic disease)
  • ALP (bony metastases)
  • PSA (bony metastases)
  • Calcium (myeloma, bony metastases)
24
Q

What imaging is done for back pain?

A
  • radiograph
  • CT
  • MRI
25
What are the pros and cons of radiographs?
- poor sensitivity, radiation - cheap, widely available
26
What are the pros and cons of CT scans?
good for bony pathology, larger radiation dose
27
What are the pros and cons of MRI scans?
- Best visualization of soft tissue structures like tendons and ligaments - Best for spinal imaging: can see spinal cord and exiting nerve roots - Expensive and time-consuming
28
What is the current NICE guidance for managing low back pain?
- injections - exercise - manipulation - psychological therapy - NSAIDs - weak opioids - radiofrequency denervation - epidural
29
What are the conservative treatment options of low back pain?
- analgesia - anti-infloammatory drugs - manipulation - acupuncture - massage - time
30
What are the red flag symptoms associated with low back pain?
- weight loss - fever - night pain - < 20 or > 55 - constant pain - thoracic pain - previous malignancy - immunosuppressed - bladder or bowel disturbance - leg weakness or sensory loss
31
What is cauda equina syndrome?
- neurosurgical emergency - spinal stenosis causing compression of the cauda equina - untreated leads to permanent lower limb paralysis and incontinence
32
What are the signs and symptoms of cauda equina?
* Saddle anaesthesia * Bladder/bowel incontinence * Loss of anal tone on PR * Radicular leg pain * Ankle jerks may be absent
33
What are the causes of cauda equina syndrome?
- disc herniation - bony mets - myeloma - TB - paraspinal abcess
34
What investigations should be done for suspected cauda equina syndrome?
Urgent lumbar spine MRI
35
What is inflammatory spondyloarthirits (SpA)?
- Group of immune-mediated inflammatory diseases - Ankylosing spondylitis (AS), psoriatic arthritis and inflammatory bowel disease (IBD)
36
Which joints are affected in SpA?
- spine (spondylitis) and sacro-iliac joints (sacro-iliitis) - peripheral joints, esp. tendon insertions (entheses), can also be affected
37
What are the extra-articular manifestations of SpA?
* Anterior uveitis (iritis) – ocular inflammation * Apical lung fibrosis * Aortitis/aortic regurgitation * Amyloidosis – due to chronically serum amyloid A (SAA) depositing in organs
38
What is ankylosing spondylitis?
- loss of spinal movements - characterised by enthesitis (inflammation of the entheses- sites where tendon and ligaments join to bone)
39
How do genetic impact ankylosing spondylitis?
- HLA-B27 is the strongest genetic risk factor, used as a diagnostic marker - polygenic
40
Which cytokines play a role in the pathogenesis of ankylosing spondylitis?
* tumour necrosis factor alpha (TNF-alpha) * interleukin-17 (IL-17) * interleukin-23 (IL23)
41
How do metastases look on an MRI?
darkening/blackening of the spinal cord
42
How does inflammatory arthropathy look on an MRI?
- lightening/whitening of the spinal cord (shiny corners) - seen before x-ray changes develop
43
What should be done in someone Under 35 and 3 months of pain?
whole spine MRI
44
How does myeloma look on an MRI?
like metastases
45
What can osteoporosis lead to?
- vertebral collapse - wedge fracture