clinical anatomy of the back (week 11)

Question 1

what are the three As used to interpret a C-spine injury?

Answer 1

Adequacy, Alignment and Asymmetry

Question 2

what does each A stand for?

Answer 2

Adequacy - can you see all 7 vertebrae and top of T1?
Alignment - draw 3 vertical parallel lines along the anterior and posterior border of the 7 vertebral bodies and a 3rd line through the base of each spinous process; Asymmetry - look for abnormal asymmetry between the 7 cervical vertebrae

Question 3

what is a hangman’s fracture?

Answer 3

caused by overextension of the neck; fracture through C2 lamina/pedicle; patient complains of pain and stiffness in neck often following a high velocity injury (a CT scan should be done to assess for degree of instability and/or vertebral artery damage as its close to the foramen transversarium

Question 4

how do you get an Xray of the C1 vertebrae?

Answer 4

by doing an open mouth Xray

Question 5

what is the transverse ligament?

Answer 5

the ligament which holds the odontoid process in place and allows rotation of the atlanto-axial joint

Question 6

what is Jefferson’s fracture?

Answer 6

a burst fracture of C1. Usually resulting from a blunt force hitting directly from crown of head. C1 bursts 4 ways around the odontoid process

Question 7

what is the owls eyes and beak?

Answer 7

used to help assess a thoracic back Xray from anterior/posterior view. Owls eyes = pedicles; owls beak= spinous process.

Question 8

what does a winking owl suggest?

Answer 8

a single or bilateral pedicle disruption. suggests possible fracture

Question 9

what does a wedge shaped vertebral body indicate on a lateral Xray of the spine?

Answer 9

a compression fracture. Common in osteoporosis after bone has become brittle.

Question 10

what are the PQRST questions asked about back pain?

Answer 10

Provocative and palliative factors; Quality of pain; radiation; severity and systemic symptoms; timing

Question 11

what are zygapophysial joints?

Answer 11

facet joints

Question 12

what do zygapophysial joints prevent in terms of movement?

Answer 12

excess rotation or lateral flexion of the vertebrae, with support from the ligamentum flavum

Question 13

what is spondylosis?

Answer 13

osteoarthritis in the synovial joints of the vertebrae (the zygapophysial joints). Common in cervical and lumbar regions. The joint becomes weak.

Question 14

what is facet joint syndrome?

Answer 14

common cause of back pain. Can be due to degenerative changes in the zygapophysial joint or the ligamentum flavum

Question 15

what is spondylolisthesis?

Answer 15

anterior slip of a vertebrae on the lower segment due to weakness of ligametum flavum or fracture of pedicle. (commonly L4/L5 or L5/S1) There may be impingement of the spinal nerve as it exits through the IV foramen.

Question 16

what is cauda equina syndrome?

Answer 16

SURGICAL EMERGENCY: a collection of symptoms and signs which result from severe compression of the descending lumbar and sacral nerve roots within the lumbar cistern.

Question 17

what is the acronym for recognition of symptoms of Cauda equine syndrome?

Answer 17

S - saddle anaesthesia 
P - pain in back and/or down both legs
I - Incontinence (bladder or bowel movements)
N - numbness in leg(s)
E - emergency

Question 18

what are some degenerative conditions which can result in cauda equine syndrome?

Answer 18

lumbar disc herniation; spondylolisthesis

Question 19

what are some traumatic causes of cauda equine syndrome?

Answer 19

vertebral fracture or dislocation; epidural haematoma

Question 20

what are some infective causes of cauda equina syndrome?

Answer 20

epidural abscess; tuberculosis

Question 21

what are some malignant causes of cauda equine syndrome?

Answer 21

metastases and primary CNS malignancies

Question 22

what are the disease mechanisms involved with degenerative changes to the intervertebral disc causing disc herniation?

Answer 22

gelatinous NP replaced with fibrous tissue, unable to bear compressive forces. weight transferred to AF causing fissures to develop. If fissure reached IV disc peripheries there is a risk of NP herniation

Question 23

what are the disease mechanisms involved with age related changes to the intervertebral disc causing disc herniation?

Answer 23

annular tears occur when the water content of IV disc declines with age, reducing tension in the AF.

Question 24

what are some other causes of lumbar IV disc herniation?

Answer 24

jobs involving heavy lifting, contact sport injuries, following trauma to the vertebral column

Question 25

what type of back pain is associated with IV disc herniation?

Answer 25

lower back pain (dull ache, worse with flexion)

Question 26

what is Sciatica?

Answer 26

pain or paraesthesia in the dermatomal distribution of sciatic nerve (nerve roots L4, 5, S1,2,3) and weakness of those myotomes

Question 27

in which direction is herniation of the IV disc most common?

Answer 27

in the poster-lateral direction, impinging on spinal nerve root, because AF is thin and lacks support of posterior longitudinal ligament

Question 28

what happens if the IV disc herniates anteriorly?

Answer 28

this is an EMERGENCY. Cauda equine syndrome or spinal cord stenosis (if above L1/L2)

Question 29

what does a winking owl in the thoracic region suggest?

Answer 29

can suggest vertebral metastasis

Question 30

what are some types of metastasis which can cause lytic lesions in the vertebrae (bone destruction)?

Answer 30

lung cancer, colorectal, renal cell carcinoma, multiple myeloma (bone marrow metastasis)

Question 31

what are some types of vertebral metastasis which can cause sclerotic lesions (abnormal bone formation, appears white)?

Answer 31

prostate and medullary thyroid cancer

Question 32

what are some types of vertebral metastasis which can cause mixed lesions?

Answer 32

breast and lymphoma

Question 33

what is osteomyelitis?

Answer 33

infection of the vertebra (also commonly long bones) in all age groups most common infection is staph. aureus bacteria

Question 34

what type of bacteria is most common in causing osteomyelitis in sickle cell disease?

Answer 34

salmonella sp. bacteria

Question 35

what is Pott’s disease?

Answer 35

pulmonary TB which has spread to vertebrae

Question 36

how do osteomyelitis infections spread?

Answer 36

in the blood stream (NB there are no valves in venous plexus’ in spine); directly (from infection in near by tissue, e.g. cellulitis); during operation on the spine.

Question 37

what is discitis?

Answer 37

infection of the intravertabral disc. Common aetiology and pathophysiology to osteomyelitis. common in intravenous drug users with subacute back pain (days-weeks)

Question 38

what is a sprain? (in terms of back pain)

Answer 38

common cause of lower back pain in athletes. ligament injury

Question 39

what is a strain? (in terms of lower back pain)

Answer 39

common cause of lower back pain in athletes. muscle or tendon injury.