Common spinal injuries

Question 1

Fractures of vertebrae

Answer 1

Fractures and fracture-dislocations usually due to sudden forceful flexion. Causes compression fractures of the body of vertebrae.

Vertebrae may become anteriorly displaced on the vertebrae inferior to it. This dislocates and fractures the articular facets and and ruptures interspinous ligaments

Question 2

Injury of zygapophyseal joints

Answer 2

Damage to facet joints affects related spinal nerves. Causes pain along the distribution of dermatomes and spasm in the muscles of the myotomes (incomplete answer)

Question 3

What is the frequency of pain experienced in each area of the spine?

Answer 3

Cervical: mobile area of the spine, bears the weight of the head. Pain caused by trauma, fractures or degenerative changes.

Thoracic: Ribcage redistributes weight of the spine, rarely experience stress-related pain. Pain commonly due to pathology e.g. TB, tumour, trauma, infection. Red flag in children

Lumbar: degenerative changes and stress-related pain

Question 4

Sources of back pain

Answer 4

Damage to muscle: lumbago, fibrositis, fibromyalgia

Damage to bone: fracture, osteoporosis, tumor, infection

Damage to IV discs: prolapse,

Damage to cartilage of the vertebral bodies

Damage/compression of nerve roots (not covered by neurolemma),referred pain

Question 5

How does IV disc prolapse cause back pain?

Answer 5

IV disc prolapse is more common in younger people because the nucleus polposus is still fluid and mobile.

If the annulus fibrosis degenerates the nucleus polposus herniates posterolaterally and can compress the spinal cord or nerve roots. Posterior roots of the spinal cord do not have a neurolemma, and are therefore more susceptible to damage.

Localised back pain is caused by compression of the longitudinal ligaments and annulus fibrosus, and from local inflammation

Chronic back pain is due to compression of the nerve roots by a herniated disc which is referred to the dermatome

Question 6

Common causes of lower back pain

Answer 6

Mechanical overuse injury

Degenerative changes in the IV discs - loss of disc height can cause the nerves to be strangled by facet joints

Osteoarthritiis - osteophytes can cause direct pressure on the nerve roots.

Question 7

Symptoms of degenerative changes in the joints

Answer 7

Stiffness - worse in the mornining or after periods of rest. Movement lubricates the joints

Intermittent pain becoming more constant as the condition progresses

Question 8

Management of lower back pain

Answer 8

Physiotherapy - postural control

Avoid causative factors

NSAIDs

Cognitive therapy (particularly for chronic pain)

Spinal injections (anaesthetics)

Question 9

Presentation of IV disc prolapse

Answer 9

Prodromal back pain

Sciatica

Muscle spasm (can result in scoliosis)

Question 10

Sciatica

Answer 10

Pain in the lower back and hip radiating down the back of the thigh to the leg.

Caused by a herniated lumbar IV disc or osteophytes that compress the L5 or S1 component of the sciatic nerve.

Compression causes pain, parasthesia, numbness and can lead to irreparable paralysis of the muscle. This requires surgical intervention.

Question 11

Rupture of the transverse ligament of atlas

Answer 11

Rupture of the transverse ligament means that the odontoid process is free, resulting in dislocation of the atlas and axis. The odontoid process may be driven into the upper cervical region of the spinal cord causing quadriplegia, or into the brainstem causing death

Question 12

Examination in a patient with sciatica

Answer 12

Spinal movements

Neurological examination: sensation

Reflexes - lost if the nerve is compressed

Straight leg raising sign

Question 13

Back sprains

Answer 13

Injury of the ligamenout tissue of the back. Results from excessively stong contractions in extension or rotation of the back.

Back strain involves stretching or tearing of muscle fibres. Caused if weight is not properly distributed on the vertebral column.

Question 14

Mangement of patiens with sciatica

Answer 14

Physiotherapy

Muscle relaxants

Disc removal if there are neurological problems

Question 15

Central disc prolapse

Answer 15

Common in L4/L5 vertebrae

Damages sacral plexus

Results in impotence, incontinence, loss of anal tone on PR exam (red flags)

Question 16

Cauda equina syndrome

Answer 16

Compression arising from a large central disc herniation at L4/L5 or L5/S1 vertebral level, tumours, trauma or spondylolisthess

Damages sacral plexus

Symptoms:
Incontinence, Impotence, Sensory changes in perineum, back pain, (asymmetrical) lower limb weakness, loss of reflexes

Assess using MRI

Question 17

Spinal claudication

Answer 17

Narrowing of the spinal canal with resulting pressure on the cauda equina

Due to osteophytes and thickening of the ligamentum flava with age spinal canal is narrowed.

Venous return to the lower limbs increases during exercise, some is redirected to the spinal plexus if return to the IVC is impaired. This further reduces the space in the spinal canal, impinging on the nerves and causing pain.

Question 18

Spondylolisthesis

Answer 18

Anterior displacement of thevertebral body relative vertebrae below

Due to degenerative changes in the facet joints or pars interarticularis fractures

If it occurs in L5 vertebrae can cause compression of the cauda equina as they pass into the superior part of the sacrum, causing back and lower limb pain.

In C2 (Hangman’s fracture)

Question 19

Pars interarticularis fractures

Answer 19

Fracture of the vertebra between the superior and inferior facet joints.

Vertebral body may slip anteriorly and compress the vertebral canal.

Common at L4 and L5

Question 20

Osteoporosis in the spine

Answer 20

Bones become weakened and brittle, so are more subject to fractures.

Increase in thoracic kyphosis due to compression of the anterior part of the vertebral body which causes progressive erosion and collapse of the vertebrae