Clinical anatomy of the spine

Question 1

Answer 1

Question 2

What kind of joints are facet joints?

Answer 2

Synovial

Question 3

What is unique about C1 (atlas) vertebra?

Answer 3

Has no vertebral body

Question 4

What is the first palpable vertebra?

Answer 4

C7 (vertebra prominens)

Question 5

What makes rotational head movements possible?

Answer 5

The odontoid process (dens) of C2 acts as a pivot within C1 allowing rotational movements

Question 6

Answer 6

Question 7

Answer 7

Question 8

Answer 8

Question 9

What are the extrinsic muscles of the spine?

Answer 9

Trapezius, latissimus dorsi, rhomboid major/minor, levator scapularis

Question 10

What are the deep muscles of the spine?

Answer 10

Erector spinae

Question 11

Regarding the spinal cord:

a) what is it?
b) where does it exit the skull?
c) where does it terminate?

Answer 11

a) inferior continuation of the medulla oblongata
b) foramen magnum
c) the cauda equina at L2

Question 12

Answer 12

Question 13

How are a) ascending and b) descending (i.e. motor) signals transmitted through the spinal cord at the level of the vertebrae?

Answer 13

a) ascending fibres enter via the dorsal root, into the posterior horn of the grey matter and into ascending sensory tracts
b) motor signals enter the anterior horn of the grey matter and exit via the ventral root, into the spinal nerve and onto the muscle of action

Question 14

What happens after the ventral and dorsal roots combine to become the spinal nerve root?

Answer 14

Divide into anterior (ventral) and posterior (dorsal) rami; posterior rami serve the muscles of the back and the thin strip of sensation in the centre of the back, anterior rami serve everything else

Question 15

What forms the intervertebral foramen?

Answer 15

The superior and inferior notches of the two adjacent vertebral pedicles

Question 16

The cauda equina is composed of which nerve roots?

Answer 16

L2-S5 and the coccygeal nerve

Question 17

What is mechanical back pain and what is it typically caused by?

Answer 17

Relapsing and remitting back pain with no neurological symptoms or “red flags”.

Typical causes- obesity, poor posture, poor lifting technique, facet joint OA, spondylosis

Question 18

What is spondylosis?

Answer 18

Loss of water content in discs with age; leading to increased pressure on facet joints and secondary OA

Question 19

How is mechanical back pain treated, and what should patients be encouraged to do?

Answer 19

Analgesia and physio; patients should be encouraged to maintain normal function (bed rest leads to stiffness and spasm)

Question 20

What is a typical history of discogenic back pain?

Answer 20

Acute onset of pain, usually after lifting a heavy object, characteristically worse on coughing

Question 21

Where is the commonest site for disc prolapse impingement?

Answer 21

Sciatic nerve (L4, L5 and S1) roots

Question 22

How does sciatica present?

Answer 22

Neuralgic pain or tingling radiating down the back of the thigh to below the knee

Question 23

How is disc prolapse typically treated?

Answer 23

Analgesia, maintain mobility

Drugs for neuropathic pain e.g. Gabapentin, amitriptylline may be useful

Question 24

What can OA of facet joints lead to? How might this be treated?

Answer 24

Bony entrapment of exiting nerve roots. Surgical decompression

Question 25

How does the claudication of spinal stenosis differ from that of peripheral vascular disease?

Answer 25

Claudication distance is inconsistent; pedal pulses are preserved; pain is burning rather than cramping; pain is less when walking uphill

Question 26

How do osteoporotic crush fractures present?

Answer 26

Spontaneously; with pain and kyphosis

Question 27

What causes cauda equina syndrome?

Answer 27

Very large disc prolapse compressing the nerve roots of the cauda equina

Question 28

What are the symptoms and signs of cauda equina?

Answer 28

Saddle anaesthesia; urinary retention; faecal incontinence; bilateral leg pain

Question 29

Why is cauda equina syndrome an emergency?

Answer 29

Prolonged compression can cause permanent nerve damage

Question 30

What examinaiton and investigation should be carried out as soon as CES is suspected?

Answer 30

PR exam; MRI

Question 31

Once the diagnosis of CES is made, what is the treatment?

Answer 31

Urgent disctectomy

Question 32

What are the “red flags” of spinal disease?

Answer 32

Extremes of age; CES symptoms; severe/constant/night pain; systemic upset