Clinical Lumbar Spine Flashcards
Which part of the spine dehydrates with age which is why you get shorter with age?
Nucleus pulposus in the intervertebral discs
Causes loss in disc height
How does dehydration of the nucleus pulposus cause further degenerative changes of the spine?
Decreased height of discs , leads to bulging of discs and therefore alteration of the load stresses on the joints
What is marginal osteophytosis?
Osteophytes called syndesmophytes develop next to the end plates of the discs due to the altered load stresses on the vertebral joints
What is Facet Joint Osteoarthritis?
Increased stress being put on facet joints due to dehydrated nucleus pulposus of intervertebral disc
Why is arthritis in the facet joints so painful?
Joint supplied by meningeal branch of spinal nerve
Intervertebral foramina narrow which can compress spinal nerves = radicular or nerve pain
What is the definition of mechanical back pain?
Pain when the spine is loaded that is worsened by exercise but relieved by rest
What are the 3 main contributing lifestyle factors to getting mechanical back pain?
Weight
Posture
Exercise
Why does lack of exercise increase chances of mechanical back pain?
Muscles around spine deconditioned (core/paraspinal)
Why does poor posture lead to mechanical back pain?
Bulges of the intervertebral discs
When flexed, posters bulge
When extended, anterior bulge
Why does heavier weight increase chances of mechanical back pain?
More force on abdomen
Osteoarthritis more likely/easier to develop
How does a patient with mechanical back pain present?
Intermittent pain
Severity of pain doesn’t scale to the action
Usually triggered by a very minor incident like tying a shoe
What is a herniation?
When an organ/tissue protrudes out of the body cavity/place it normally lies in
What are the 4 stages to a prolapsed invertebrates disc/slipped disc/Herniated disc?
Degeneration (Disc bulges with age as nucleus pulposus dehydrates)
Prolapse
Extrusion
Sequestration
What happens at the prolapse stage of a slipped disc?
Protrusion of the nucleus pulposus occurs slightly impinging the spinal canal
Acidic nucleus pulposus still contained in annulus fibrosus
What happens at the extrusion stage of disc herniation/slipped disc?
Nucleus pulposus breaks through the annulus fibrosus but still stays in the disc space or doesn’t sink down
What happens at the sequestration stage of a slipped/prolapsed/herniated disc?
Nucleus pulposus breaks through annulus fibrosis and separates from main body of the disc in the spinal canal
Why does the nucleus pulposus normally herniate posterolaterally? (Paracentral prolapse)
Passes to the side of the posterior longitudinal ligament
In a paracentral herniation what nerve root is at risk of being irritated/compressed (lumbar spine)?
How does this compare to the cervical spine?
Traversing root
Almost always the nerve root associated with the lower vertebra affected
L4/L5 paracentral herniation = compressed L5 nerve root
Cervical spine = emerging root since cervical spinal nerves emerge above their associated vertebrae
What condition can central herniation/prolapse of an intervertebral disc cause?
Cauda equina syndrome
Prolapsed intervertebral discs usually heal, why is some of the nucleus pulposus permanently lost?
White cells in the CSF resorb the portion protruding into the spinal canal
Do paracentral herniation of an invertebral disc usually cause unilateral or bilateral effects?
Usually unilateral
Side effected which has the compressed root
What is Sciatica?
Pain cause by the irritation or compression of 1 or more of the nerve roots which contribute to the sciatic nerve (L4-S3)
What are the nerve roots of the sciatic nerve?
How to remember nerve roots of sciatic?
L4
L5
S1
S2
S3
Split scia_tic in half. 4 Letters = L4. 3 letters = S3
So sciatic = L4 - S3
What can cause sciatica?
Marginal osteophytosis
Slipped disc
How is pain experienced in sciatica?
Radiates from the lumbar spine to the Dermatome which the compressed spinal root supplies
Where does the pain radiate if someone has L4 sciatica?
Anterior thigh
Anterior knee
Medial leg
Runs down front of leg
Where does the pain radiate if someone has L5 sciatica?
Lateral thigh
Lateral leg
Dorsum of foot
Where does the pain radiate if someone has S1 sciatica?
Posterior thigh
Posterior leg
Heel
Lateral border and sole of foot
If the nerve compression in sciatica causes parasthesia, where is the parasthesia experienced?
Only the affected Dermatome
E.g If L4 spinal root compressed only L4 Dermatome (medial leg) affected
What is Cauda Equina Syndrome?
Compression of lumbar and sacral nerve roots
Can be by a spinal canal filling prolapsed intervertebral disc/herniated disc
What age do disc prolapses most commonly occur?
30-50yrs
What are the 5 red flag symptoms of Cauda Equina Syndrome?
Bilateral sciatica
Perianal numbness (saddle anaesthesia)
Painless retention of urine
Urinary/faecal incontinence
Erectile dysfunction
When must Cauda equina syndrome be treated and how?
Surgical Decompression, within 48 hours of sphincter disturbance (urine/faecal incontinence)
If missed patient will need to forever self catheterise, empty bowels by looking at clock, chronic neuropathic pain and may need a wheelchair
How can Cauda equina syndrome be diagnosed?
MRI
Check Perianal tone (insert finger and see if they can contract, called the anal wink)
What are the complications of not treating Cauda equina syndrome in time?
Incontinence
Chronic neuropathic pain
Poor sexual experience
Impotence (infertility)
What is Lumbar canal stenosis?
Narrowing of the spinal canal that compresses either the spinal cord or nerve roots
What age group does lumbar canal stenosis tend to affect?
Elderly
What usually leads to lumbar canal stenosis?
Disc bulge (ageing dehydration)
Facet joint osteoarthritis
Ligamentum flavum hypertrophy
What is a common symptom of Lumbar canal stenosis?
Neurogenic claudication
What is claudication?
Pain in legs whilst walking
(Heaviness, weakness, wobbliness and increasing pins + needles)
How does Lumbar canal stenosis cause neurogenic claudication?
Compression of nerve roots leads to veins being engorged in exercise
Reduces arterial blood flow to the nerves
Leads to temporary ischaemia of affected nerves this causes the pain
Why does a change in position by Flexion help relieve neurogenic claudication?
Leads to spinal canal enlarging so nerves not compressed
Ligamentum flavum tension widens canal
Posterior part of annulus fibrosis tightened reducing bulge
Full blood supply
What other symptoms are there for lumbar canal stenosis?
Discomfort while standing
Discomfort or pain in lower limb’
Cervical stenosis = pain in shoulder, arm or hand
Bilateral symptoms
Numbness and weakness below level of stenosis
How is lumbar canal stenosis treated?
Laminectomy
Surgical decompression to restore spinal canal dimensions
What is a laminectomy?
Remove half of facet joint either side
Remove ligamentum flavum
Remove spinous process
What is the meaning of Spondylolisthesis?
The forward shift/slip of one vertebra relative to the vertebra below
The top vertebra moves forward to the bottom one
How do you spot spondylolisthesis?
Follow the posterior lines running up and down either side of the spine
If there is a step the, a vertebra has slipped and this is spondylolisthesis
What is a lumbar puncture?
Needle is inserted into the subarachnoid space to withdraw Cerbrospinal fluid
What position should a patient be in to take a lumbar puncture?
Lie on side
Back flexed and hips flexed (knees to chest position)
At what vertebrae does the spinal cord end?
What is this point called?
What does the spinal cord become?
L1
Conus medullaris
Cauda equina
What is the end of spinal cord called?
Conus medullaris
How can you locate your L4-L5 gap?
Its at the midline if you draw a line joining your 2 iliac crests together
At what spinal level would you perform a lumbar puncture?
Below L1 so:
L2/L3
L3/L4
L4/L5
Why are lumbar punctures performed at L2/L3, L3/L4, or L4/L5?
Here the spinal cord is not present only the mobile spinal nerve roots of the Cauda equina
There is much less chance of neurological damage
What are the 3 meninges that surround the spinal cord/Cauda equina?
Dura mater (Outer)
Arachnoid mater
Pia mater (Inner)
With a lumbar puncture where must the needle travel through to reach the CSF?
At what point is the pop felt?
Skin
Subcutaneous fat
Supraspinous ligament
Interspinous ligament
Ligamentum flavum (Pops when pushed through)
Dura mater
Arachnoid mater
Subarachnoid space is where the CSF is located
