Ch 11 - Pain Management: Spine Pain Flashcards
What are common causes of nerve root irritation?
Herniated intervertebral disc Spinal stenosis Synovial facet cysts Infection Malignancy
How does leakage of nucleus pulpsus lead to pain?
Inflammatory processes and release of phospholipase A2, which ultimately
sensitizes nerve endings and generates pain
How can pain from a herniated disc be aggravated?
Bending
Sitting
Coughing
How can pain from spinal stenosis be aggravated?
Walking
Relived by bending
Describe the divisions of the dorsal ramus of the nerve root
Lateral branch
Intermediate branch
Medial branch
What does the lateral branch of the dorsal rami intervate?
Paraspinal muscles
Skin
Sacroiliac (SI) joint
What does the intermediate branch of the dorsal rami innervate?
Longissimus muscle
What does the medial branch of the dorsal rami innervate?
Facet joint
Multifidus muscle
Interspinal ligament and muscle
Periosteum of neural arch
Describe the innervation of lumbar facet joints
Each facet is innervated by the medial branch at the same level and the level above
(L4–L5 facet joint is mediated by the L3 and L4 medial branches)
Which level does not have a medial branch nerve?
L5 dorsal rami, it directly innervates the facet joint
Describe the innervation of cervical and thoracic facet joints
Each facet is innervated by the medial branches of corresponding dorsal rami
(C5–C6 facet joint is innervated by the C5 and C6 medial branches).
How is the C2-C3 joint innervated?
Dorsal ramus of C3
What does the dorsal ramus of C3 divide into?
Two medial branches, the larger branch is the 3rd occipital nerve
Describe the clinical presentation of facet mediated pain
Axial spine and referred pain to the extremities
Aggravated by lateral bending, extension twisting, and applying load on torsion.
Describe interventional treatment for facet mediated pain
Facet blocks
Medial branch nerve blocks
Radiofrequency ablation
What innervates intervertebral discs?
Posterior: sinuvertebral nerves
Laterally: Ventral rami
Anterolaterally: gray rami communicantes
What is a Dallas grade 0 of annular disruption?
No annular disruption
What is a Dallas grade 1 of annular disruption?
Nucleus pulposus (NP) leaking into inner annulus
What is a Dallas grade 2 of annular disruption?
NP leaking into outer annulus
What is a Dallas grade 3 of annular disruption?
NP leaking beyond outer annulus
Describe Modic Type I changes
Marrow is substituted by serum
Bright on T2, dark on T1 (edema)
Describe Modic Type II changes
Marrow is substituted by visceral fat
Bright on T2 and T1 (fat)
Describe Modic Type III changes
Bone scar tissue
Dark on T2 and T1 (bony sclerosis)
Describe spinal stenosis
Focal narrowing of the central spinal canal that causes compression of the spinal cord (cervical or thoracic) or spinal nerves (lumbar)
What are the presenting features for spinal stenosis pain?
Lower limb or buttock pain exacerbated by prolonged standing or walking and relieved with lumbar flexion
What is the lifetime return to work rate for injured workers off from work for 6 months, one year and 2 years?
6 months: 50%
1 year: 25%
2 years: <5%
