Clinical spine

Question 1

How to identify spine sections on X ray

Answer 1

for AP:
Owls face
Eyes of owls = pedicles
Owls beak = spinous process
Vertebral body = head
Transverse processes stick out to side

Question 2

Imaging for spine:

Answer 2

X-ray (AP and Lateral)
CT
MRI for ligaments

Question 3

Common to least common lumbar pathology

Answer 3

Mechanical back pain
Prolapsed intervertebral disc
Spinal Stenosis
Spondylolisthesis 
Spinal infection/tumour

Question 4

Causes of mechanical back pain

Answer 4

Bad posture (can be from poorly designed seating)
Little exercise
Obesity
Incorrect manual handling

Question 5

Mechanical back pain characterised by

Answer 5

Pain when the spine is loaded
Worse with exercise
Relieved by rest

Question 6

What happens as spine ages?

Answer 6

Loss of height of disc = disc bulging
Osteophytes (syndesmophytes from marginal osteophytosis)
Facet joint OA

Question 7

What occurs when facet joints get OA?

Answer 7

PAIN (innervated by meningeal branch of spinal nerves)

Question 8

Ultimate result of decreased disc height, OA in facet joints?

Answer 8

Intervertebral foramina decrease in size = compression of spinal nerves

Question 9

Pain caused by compression of spinal nerve

Answer 9

Radicular / Nerve pain

Question 10

What occurs during herniation of disc?

Answer 10

‘slipped disc’

Nucleus pulposus protrudes and compresses spinal nerve

Question 11

4 stages of disc herniation

Answer 11

Disc degeneration
Prolapse
Extrusion
Sequestration

Question 12

Disc degeneration

Answer 12

ageing = chemical changes

discs dehydrate and bulge

Question 13

Prolapse

Answer 13

Protrusion of nucleus pulposus slightly into spinal canal

*Still contained within annulus fibrosus

Question 14

Extrusion

Answer 14

Nucleus pulposus breaks through annulus fibrosus but still contained within disc space

Question 15

Sequestration

Answer 15

Nucleus pulposus seperates from main body of disc and enters spinal canal

Question 16

Most common sites for slipped disc

Answer 16

L4/5
L5/S1
(from mechanical loading)

Question 17

When are nerve roots most vulnerable?

Answer 17

Crossing intervertebral disc paracentrally

When they exit spinal canal via intervertebral foramina

Question 18

Paracentral prolapse

Answer 18

most common (96%)
Posterolaterally (PLL prevents straight posterior)
TRAVERSING nerve root affected

Question 19

Other prolapse

Answer 19

Far lateral (2%)
Central (2%) towards spinal cord (risk of cauda equina syndrome)

Question 20

Exiting root

Answer 20

Nerve that exits spinal canal at same level as disc

Question 21

Traversing root

Answer 21

Nerve root that emerges level below the disc

Affected in paracentral prolapse

Question 22

If paracentral herniation occured at L4/5 which root would be affected?

Answer 22

L5 as its traversing

Question 23

What is sciatica?

Answer 23

Pain caused by irritation or compression to one of the spinal nerves contributing to the sciatic nerve

(L4 L5 S1 S2 S3)

Question 24

Where is pain usually experienced in sciatica?

Answer 24

Back and buttock

radiates to dermatome supplied by that root (follows path)

Question 25

L4 sciatica pain

Answer 25

Anterior thigh, anterior knee and medial leg

Question 26

L5 sciatica pain

Answer 26

Lateral thigh, lateral leg, dorsum of foot

Question 27

S1 sciatica pain

Answer 27

Posterior thigh, posterior leg, heel, sole of foot

Question 28

Where is parasthesia experienced in sciatica?

Answer 28

ONLY in affected dermatome (not full path)

Question 29

Cauda equina syndrome possibly

Answer 29

Prolapsed intervertebral disc filling spinal canal

Question 30

Other causes Cauda equina syndrome

Answer 30

``` Tumours Infection/abscess Spinal stenosis (from OA) Fracture in vertebrae Spinal haemorrhage Late stage Ankylosing spondylitis ```

Question 31

RED FLAG for Cauda equina

Answer 31

``` Bilateral Sciatica Perianal numbness Painless retention of urine Urinary/faecal incontinence Erectile dysfunction ```

Question 32

Treatment Cauda equina syndrome

Answer 32

Surgical decompression urgently (otherwise: chronic neuropathic pain, self catheterisation, faecal incontinence, loss of sensation/weakness in lower limb = WHEELCHAIR)

Question 33

Spinal canal stenosis

Answer 33

Abnormal narrowing of spinal canal compresses spinal cord or nerve roots

Question 34

Who and why spinal stenosis?

Answer 34

Elderly Disc prolapse, Facet OA, Ligamentum flavum hypertrophy

Question 35

Other not so common causes of spinal stenosis

Answer 35

Compression fractures of vertebral bodies Spondylolisthesis Trauma

Question 36

Symptoms of spinal stenosis

Answer 36

``` Pain when standing Discomfort in shoulder/arm/hand (cervical) or lower limb (lumbar) Numbness at and below stenosis Weakness at and below Neurogenic claudication ```

Question 37

Neurogenic claudication - what does it feel like

Answer 37

symptom pain/pins and needles in the legs after prolonged standing/walking radiating sciatica distribution

Question 38

Claudication meaning

Answer 38

Latin for limb | cramping/weakness in legs = limp

Question 39

Neurogenic claudication cause

Answer 39

Compression of spinal nerves as they emerge from lumbosacral spinal cord/cauda equina

Question 40

What happens to neurogenic claudicated nerved during exercise?

Answer 40

Venous engorgement Reduced arterial inflow Arterial ischaemia = pain/paraesthesia

Question 41

How is neuroclaudication relieved?

Answer 41

Rest Change in position Flexion of spine (open canal)

Question 42

Spondylolisthesis

Answer 42

Anterior displacement of vertebrae above relative to vertebrae below

Question 43

How is spondylolisthesis spotted on x ray?

Answer 43

Scotty dog outline on oblique xray of spine If dog wearing collar = stress fracture (spondylolysis) If dogs head detatched from body = spondylolisthesis

Question 44

Spondylolysis

Answer 44

Fracture in pars interarticularis | between superior and inferior articulating processes

Question 45

Lumbar puncture

Answer 45

Withdrawal of fluid from subarachnoid space of lumbar cistern (filled with CSF)

Question 46

Patient position lumbar puncture

Answer 46

Patient on side back and hips flexed (knees to chest) =Spreads apart vertebral lamina and spinous processes and stretches ligamentum flavum

Question 47

Where is lumbar puncture needle inserted?

Answer 47

Midline between spinous processes of L3 and L4 | or L4 and L5

Question 48

How can this lumbar location be located?

Answer 48

Plane transecting highest points of iliac crest (supracristal plane) no danger damaging spinal cord here

Question 49

What happens during lumbar puncture?

Answer 49

``` Passes 4-6cm in adults (through skin and subcutaneous fat) needle 'pops' through ligamentum flavum epidural fat and veins punctures dura mater punctures arachnoid mater enters lumbar cistern ```

Question 50

Layers of mater

Answer 50

``` Epidural space Dura mater Arachnoid mater CSF Pia mater at base ```