Back Anatomy and Management of a Slipped Disc Flashcards
What is the function of the spine?
- locomotor function
- protects the spinal cord
- spinal cord transmission of signals between brain and periphery
What is the spinal column made up of?
- vertebrae
- intervertebral discs
- facet joints
How many spinal vertebrae are there?
24
- 7 cervical
- 12 thoracic
- 5 lumbar
What is the role of the intervertebral discs?
shock absorbers, allow segmentation & multi-directional movement
What is the role of the facet joints?
small synovial joints at posterior spinal column linking each vertebra
What are the key neurologial structures of the spine?
- vertebrae
- cauda equina
- nerve roots
Where does the spinal cord end and corda equina start?
L2
Where do the nerve roots exit the spinal cord?
Bilaterally
What are the different movements of the spine?
- flexion (bending forward)
- extension (bend back)
- rotation
- lateral flexion (side bend)
What is chronic back pain?
- back pain > 12 weeks
- can be due to sedentary lifestyle
What is non-specific low back pain?
pain not due to any specific or underlying disease that can be found
What is mechanical low back pain?
- Pain after abnormal stress and strain on the vertebral column
- Reproduced or worse with movement
- Better or not present at rest
What are the common causes of mechanical back pain?
- Muscular tension (e.g. chronic poor posture, weak muscles)
- Acute muscle sprain/spasm
- Degenerative disc disease
- Osteoarthritis of facet joints
What is nerve root pain (sciatica)?
- 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
What determines the location of the pain caused by sciatica?
The level of the herniated disc
What is the natural history of a herniated disc?
- most prevalent age 30-50
- good outlook
- normally spontaneous improvement but slower than lower back pain alone
What is the treatment for a herniated disc?
- 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
What are the serious causes of back pain?
- tumour
- infection
- inflammatory spodnyloarthropathy
- fracture
- large disc prolapse
- referred pain
What are the different infections which could cause back pain?
- Discitis
- Vertebral osteomyelitis
- Paraspinal abcess
- Microbiology: Staphylococcus, streptococcus, tuberculosis
What are the different inflammatory spondyloarthropathies?
- ankylosing spondylitis
- psoriatic arthritis
- inflammatory bowel disease (IBD)-associated
What is the current NICE guidance for investigatinf back pain?
- 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
-
What are the treatments for lower back pain with no red flags?
- Time
- Analgesia (NSAIDs e.g. ibuprofen, paracetamol, codeine)
- AVOID bed rest: keep moving
- Physiotherapy (Soft tissue work, Corrective exercises esp. core)
Which blood tests are done for back pain?
- 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)
What imaging is done for back pain?
- radiograph
- CT
- MRI
What are the pros and cons of radiographs?
- poor sensitivity, radiation
- cheap, widely available
What are the pros and cons of CT scans?
good for bony pathology, larger radiation dose
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
What is the current NICE guidance for managing low back pain?
- injections
- exercise
- manipulation
- psychological therapy
- NSAIDs
- weak opioids
- radiofrequency denervation
- epidural
What are the conservative treatment options of low back pain?
- analgesia
- anti-infloammatory drugs
- manipulation
- acupuncture
- massage
- time
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
What is cauda equina syndrome?
- neurosurgical emergency
- spinal stenosis causing compression of the cauda equina
- untreated leads to permanent lower limb paralysis and incontinence
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
What are the causes of cauda equina syndrome?
- disc herniation
- bony mets
- myeloma
- TB
- paraspinal abcess
What investigations should be done for suspected cauda equina syndrome?
Urgent lumbar spine MRI
What is inflammatory spondyloarthirits (SpA)?
- Group of immune-mediated inflammatory diseases
- Ankylosing spondylitis (AS), psoriatic arthritis and inflammatory bowel disease (IBD)
Which joints are affected in SpA?
- spine (spondylitis) and sacro-iliac joints (sacro-iliitis)
- peripheral joints, esp. tendon insertions (entheses), can also be affected
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
What is ankylosing spondylitis?
- loss of spinal movements
- characterised by enthesitis (inflammation of the entheses- sites where tendon and ligaments join to bone)
How do genetic impact ankylosing spondylitis?
- HLA-B27 is the strongest genetic risk factor, used as a diagnostic marker
- polygenic
Which cytokines play a role in the pathogenesis of ankylosing spondylitis?
- tumour necrosis factor alpha (TNF-alpha)
- interleukin-17 (IL-17)
- interleukin-23 (IL23)
How do metastases look on an MRI?
darkening/blackening of the spinal cord
How does inflammatory arthropathy look on an MRI?
- lightening/whitening of the spinal cord (shiny corners)
- seen before x-ray changes develop
What should be done in someone Under 35 and 3 months of pain?
whole spine MRI
How does myeloma look on an MRI?
like metastases
What can osteoporosis lead to?
- vertebral collapse
- wedge fracture
