Clincal Conditions Of The Lumbar Spine Flashcards
What worsens and eases back pain?
Worsens- exercise
Eases - rest
Risk factors for back pain
Obesity
Poor posture
Poorly designed seating
Inactivity
Incorrect manual handling techniques
Outline disc degeneration and how to leads to marginal osteophytosis
- nucleus pulposus of IV discs dehydrate with age»_space; reduced height + bulging of discs
- osteophytes called syndesmophytes develop adjacent to end plates of discs
- this is called marginal osteophytosis
What is sciatica?
Pain caused by irritation or compression of 1+ nerve roots of sciatic nerve L4-S3
Causes of sciatica
Marginal osteophytosis
Slipped disc
Where does pain occur in sciatica?
Back + buttock + radiates to affected dermatome
Where does paraesthesia occur in sciatica?
Only in affected dermatome no radiation
Where is pain typically in L4 sciatica?
Anterior thigh
Anterior knee
Medial leg
Where is pain typically in L5 sciatica?
Lateral thigh
Lateral leg
Dorsum of foot
Where is pain typically in S1 sciatica?
Posterior thigh
Posterior leg
Heel
Sole of foot
Who is cauda equina syndrome typically seen in?
30-50 year olds
What is the most common cause of cauda equina syndrome?
Disc prolapse
Causes of cauda equina
- Disc prolapse
- Tumours affecting vertebral column or meninges
- Spinal infection/abscess or haemorrhage
- Spinal stenosis
- Vertebral fracture
- Late stage ankylosing spondylitis
Red flag symptoms of cauda equina syndrome
- Urinary/faecal incontinence
- Erectile dysfunction
- Painless retention of urine
- Perianal numbness (saddle anaesthesia)
- Bilateral sciatica
Treatment of cauda equina syndrome
Surgical decompression within 48 hours of onset
Consequences of missing diagnosis of cauda equina syndome
Impotence - ED
Faecal incontinence
Loss of sensation + weakness to lower limbs
Self catheterisation to pass urine
What are the 4 stages of disc herniation?
1- disc degeneration - ageing causes disc to dehydrate + bulge
2- prolapse - protrusion of nucleus pulposus with slight impingement into spinal canal
3- extrusion - nucleus pulposus breaks through annulus fibrosus, contained within disc space
4- sequestration - nucleus pulposus separates from disc + enters spinal canal
What happens in disc degeneration?
Chemical changes due to ageing cause discs to dehydrate and bulge
What happens in disc prolapse?
Protrusion of nucleus pulposus with slight impingement into spinal canal
What happens in disc extrusion?
Nucleus pulposus breaks through annulus fibrosus
Still contained within disc space
What happens in disc sequestration?
Nucleus pulposus separates from disc
Enters spinal canal
Where is the most common site for a slipped disc and why?
L4/5
L5/S1
Due to mechanical loading on joints
Where are nerve roots most vulnerable?
- Where they cross the IV disc (paracentrally)
- Where they exit the spinal canal in the IV foramen (far laterally)
How does the nucleus pulposus most commonly herniate?
What does this cause?
Posteolaterally
Paracentral prolapse
Compression on spinal nerves within IV foramen
What nerve root is most at risk in far lateral disc herniation?
Exiting nerve root - emerges at same level as IV disc
What type of disc herniation is the exiting nerve root most likely to be impacted by?
Far lateral disc herniation
What nerve root is most at risk in paracentral disc herniation?
Transversing nerve root - emerges at level below IV disc
What type of disc herniation is the transversing nerve root most likely to be impacted by?
Paracentral
What nerve root is most at risk in a Paracentral herniation of L4/L5 IV disc?
L5 - transversing root
What nerve root is most at risk in a Paracentral herniation of L5/S1 IV disc?
S1 - transversing nevre root
What does central herniation have a risk of?
Cauda equina syndrome
What is spinal canal stenosis?
Abnormal narrowing of spinal canal
Compresses spinal cord or nerve roots
Who is most commonly affected by spinal canal stenosis?
Elderly people
Causes of spinal canal stenosis
Disc bulging
Facet joint OA
Ligamentum flavum hypertrophy
Compression fractures of vertebral bodies
Spondyolistheis
Trauma
Where is spinal canal stenosis most common?
Lumbar spine
Then cervical
Symptoms of spinal cord stenosis
- Discomfort standing
- Numbness + weakness at or below level of stenosis
- Neurogenic claudications
Lumbar - discomfort in lower limbs
Cervical - discomfort in shoulder, arm or hand
What is neurogenic claudication?
Limp due to nerve injury/compression
Pain +/- Paraesthesia in legs on prolonged standing or walking
Cramping pain or weakness in leg
Cause of neurogenic claudications
1- Compression of spinal nerves
2- venous engorgement of nerve roots during exercise
3- decreased arterial flow
4- transient arterial ischaemia
5- pain +/- paraesthesia
What is neurogenic claudication relieved by?
Rest - most effective
Change in position
Flexion of spine e.g. walking up stairs, pushing a trolley
What is spondylolisthesis?
Anterior displacement of vertebra from vertebra below
Types of spondylolisthesis?
Congential
Isthmic - defect in pars inter articularis
Degenerative
Traumatic
Pathological
Iatrogenic
What is spondylolysis?
Complete fracture of pars interartuclauris
What is typically seen on an x ray of a patient with sponylolisthesis?
Scottie dog shape
Visible anterior displacement of vertebra
What is a lumbar puncture?
Withdrawal of fluid from subarachnoid space of lumbar cistern
What is a lumbar puncture used for?
To test for CNS disorders
e.g. MS + meningitis
Outline the process of a lumbar puncture
1- patient must be lying on side with back + hips flexed
2- skin is anaesthetised
3- lumbar puncture needle inserted between L3+L4
4- needle goes through supraspinous ligament, interspinous ligament, ligamentum flavum, dura + arachnoid, lumbar cistern
5- CSF is removed
How must a patient be lying for a lumbar puncture and why?
- Lying on side with back and hips flexed
- Flexes vertebral column > spreads apart vertebral laminae + spinous processes
What structures does the lumbar puncture needle go through in order?
- skin
- SC tissue
- supraspinous ligament
- interspinous ligament
- Ligamentum flavum
- Dura + arachnoid
- Lumbar cistern
What is cauda equina syndrome?
Condition which occurs when the cauda equina is compressed due to herniated disc, tumour, infection or trauma in lower spine
