Clinical conditions of the spine

Question 1

what is mechanical back pain?

Answer 1

back pain that is characterised by pain when the spine is loaded,
that worsens with exercise and is relieved by rest. intermittent.

Question 2

what are risk factors for mechanical back pain?

Answer 2

obesity
poor posture
a sedentary lifestyle with deconditioning of the paraspinal (core) muscles
poorly-designed seating incorrect manual handling (bending and lifting) techniques

Question 3

the nucleus propulsus dehydrates with age. what pathology can this lead to?

Answer 3

decrease in the height of discs
bulging of the discs
alteration of the load stresses on the joints

Question 4

why are osteoarthritic changes in the facet joints perceived as painful?

Answer 4

The facet joints are innervated by the meningeal branch of the spinal nerve, so arthritis in these joints is perceived as painful.

Question 5

how does decrease in disc height result in pain?

Answer 5

the intervertebral foramina decrease in size which can lead to compression of the spinal nerves and is perceived as radicular or nerve pain

Question 6

what are syndesmophytes?

Answer 6

osteophytes that occur adjacent to the end plates of discs. Occur in marginal osteophytosis

Question 7

what is a slipped disc?

Answer 7

herniation of the intervertebral disc into the spinal canal. The nucleus pulposus protrudes out of the annulus fibrosis and presses on the spinal nerve causing pain

Question 8

what is the most common age group for disc herniation?

Answer 8

30 to 50 years

Question 9

what are the 4 stages of disc herniation?

Answer 9

1. Disc degeneration: chemical changes associated with ageing cause discs to dehydrate and bulge
2. Prolapse: Protrusion of the nucleus pulposus occurs with slight impingement into the spinal canal. The nucleus pulposus is contained within a rim of annulus fibrosus
3. Extrusion: The nucleus pulposus breaks through the annulus fibrosus but is still contained within the disc space
4. Sequestration: The nucleus pulposus separates from the main body of the disc and enters the spinal canal.

Question 10

in which direction are disc herniations most common?

Answer 10

paracentral prolapse - posterolaterally due the posterior longitudinal ligament

Question 11

what nerves are usually compressed in a disc herniation?

Answer 11

the traversing nerve root within the intervertebral foramen.

Question 12

what is radicular leg pain

Answer 12

also known as sciatica, it is the name given to pain caused by irritation or compression of one or more of the nerve roots that contribute to the sciatic nerve (i.e. L4, L5, S1, S2 and S3)

Question 13

where is the pain experienced in sciatica?

Answer 13

pain is experienced from the back and buttock and radiates to the dermatome supplied by the affected nerve root

Question 14

what are the causes of cauda equina syndrome?

Answer 14

prolapsed intervertebral disc compressing the lumbar and sacral nerve roots
primary or secondery tumours affecting the vertebral column or meninges
spinal infection or abscess
spinal stenosis secondary to arthritis
vertebral fracture
spinal haemorrhage
late stage ankylosing spondylitis

Question 15

what are the red flag symptoms of cauda equina syndrome?

Answer 15

Bilateral sciatica
 Perianal numbness (saddle anaesthesia)
 Painless retention of urine
 Urinary / faecal incontinence
 Erectile dysfunction

Question 16

what is the management of cauda equina syndrome?

Answer 16

surgical decompression within 48 hours of the onset of sphincter symptoms, otherwise the prognosis is poor

Question 17

why is cauda equina syndrome a surgical emergency?

Answer 17

failure to treat quickly results in life-changing consequences such as:
chronic neuropathic pain
impotence
having to perform intermittent self-catheterisation to pass urine
faecal incontinence or impaction requiring manual evacuation of faeces
loss of sensation and lower limb weakness requiring a wheelchair

Question 18

what is spinal canal stenosis?

Answer 18

abnormal narrowing of the spinal canal that compresses either the spinal cord or the nerve roots.

Question 19

what are the main causes of spinal canal stenosis?

Answer 19

Disc bulging  
Facet joint osteoarthritis
Ligamentum flavum hypertrophy
Other causes include:
Compression fractures of the vertebral bodies   Spondylolisthesis 
Trauma

Question 20

what are the symptoms of spinal stenosis?

Answer 20

Discomfort whilst standing (95% of patients)
Discomfort or pain in the shoulder, arm or hand (for cervical stenosis) or in the lower limb (for lumbar stenosis)
Bilateral symptoms in approximately 70% of patients
Numbness at or below the level of the stenosis
Weakness at or below the level of the stenosis Neurogenic claudication

Question 21

what is neurogenic claudication?

Answer 21

neurogenic claudication is the symptom of pain and/or pins and needles in the legs on prolonged standing and on walking, radiating in a sciatica distribution

Question 22

what causes neurogenic claudication?

Answer 22

compression of the spinal nerves as they emerge from the lumbosacral spinal cord, usually due to spinal canal stenosis. This leads to venous engorgement of the nerve roots during exercise, leading to reduced
arterial inflow and transient arterial ischaemia. The ischaemia of the affected nerve(s) results in the pain and/or paraesthesia

Question 23

what is spondylolisthesis?

Answer 23

Spondylolisthesis is anterior displacement of the vertebra above relative to the vertebra below. May, or may not, be associated with gross instability of the vertebral column

Question 24

what is the pars interarticularis?

Answer 24

part of the vertebra between the superior and inferior articular processes

Question 25

what is spondylolysis?

Answer 25

A complete fracture in the pars interarticularis without displacement of the vertebrae

Question 26

what are the symptoms of spondylolisthesis?

Answer 26

Some individuals remain asymptomatic, but most complain of some discomfort ranging from occasional lower back pain to incapacitating mechanical pain, sciatica from nerve root compression, and neurogenic claudication.

Question 27

what is the treatment of spondylolisthesis?

Answer 27

surgery including screws and rods to stabilise the spine

Question 28

what is a lumbar puncture?

Answer 28

withdrawal of fluid from the subarachnoid space of the lumbar cistern. It is an important diagnostic test for a variety of central nervous system disorders including meningitis, multiple sclerosis etc.

Question 29

describe how to do a lumbar puncture

Answer 29

Patient lies on the side with the back and hips flexed - Flexion of the vertebral column facilitates insertion of the needle by spreading apart the vertebral laminae and spinous processes, stretching the ligamentum flavum. Anaesthetise the skin , and insert the needle in the midline between the spinous processes of the L3 and L4 (or L4 and L5) vertebrae (highest points of the iliac crests—passes through the L4 spinous process). After passing 4–6 cm in adults the needle “pops” through the ligamentum flavum, then punctures the dura and arachnoid, and enters the lumbar cistern. When the stylet is removed, CSF escapes and can be collected.

Question 30

what structures does the needle pass through in a lumbar puncture?

Answer 30

``` skin subcutaneous fat supraspinous ligament interspinous ligament ligamentum flavum epidural fat and veins dura mater arachnoid mater subarachnoid space ```

Question 31

what are the different types of disc herniation?

Answer 31

paracentral far lateral central or canal filling