Conditions Of The LUMBAR Spine

Question 1

Mechanical back pain definition, risks

Answer 1

50% UK report lumbar back for at least 24hrs any year, pain when spine is loaded, worsens with exercise

Obesity, poor posture, sedentary lifestyle, deconditioning of paraspinal muscles, poor seating, incorrect manual handling

Question 2

Degenerative changes

Answer 2

Nucleus pulposus dehydrates with age -> decrease height of discs/ bulging/ alteration of load stresses on joints -> sydesmophytes(bony spurs) osteophytes develop adjacent end plates of discs = marginal osteophytosis. Facet joints also osteoarthritic changes. Intervertebral foramina decrease size-> compression spinal nerves radicular/ nerve pain

Question 3

Herniation of an intervertebral disc ‘slipped disc’ 4 stages and 3 types

Answer 3

30-50yrs, 90% resolve by 3 months

1. DISC DEGENERATION- chemical changes discs dehydrate & bulge
2. PROLAPSE- protrusion of nucleus pulposus, slight impingement into spinal canal, contained within rim annulus fibrosus
3. EXTRUSION- nucleus pulposus breaks through annulus fibrosus still within disc space
4. SEQUESTRATION- nucleus pulposus separates from main body of disc and enters spinal canal

Most common L4/L5 and L5/S1

Traversing Nerve roots vulnerable in paracentral herniation 96% & exiting nerve roots vulnerable in lateral herniation. Central herniation -> cauda equina syndrome

Question 4

Radicular leg pain ‘Sciatica’ cause, symptoms, where

Answer 4

Pain caused irritation/ compression one or more nerve roots -> sciatic nerve (L4/5, S1/2)

Causes: marginal osteophytosis, slipped disc

Pain back and buttock, radiates dermatome supplied

L4- anterior thigh, anterior knee, medial leg
L5- lateral thigh, lateral leg, dorsum
S1- posterior thigh, posterior leg, heel, sole

Paraesthesia dermatome only

Question 5

Cauda equina syndrome what, causes, symptoms, consequences, treatment

Answer 5

Prolapsed intervertebral disc, canal filling disc compresses lumbar and sacral nerve roots within spinal canal, tumour, spinal infection, abcess, spinal stenosis secondary to arthritis, vertebral fracture, spinal haemorrhage, anklyosing spondylitis

Red flag: bilateral sciatica, perianal numbness (saddle anaesthesia), painless retention urine, urinary/ faecal incontinence, erectile dysfunction -> chronic neuropathic pain, impotence, self-catheterisation, lower limb weakness wheelchair

✅surgical decompression within 48hrs sphincter symptoms

Question 6

Spinal canal stenosis what, who, cause

Answer 6

Abnormal narrowing spinal canal compresses spinal cord or nerve roots

Elderly

Disc bulging, facet joint osteoarthritis, ligamentous flavum hypertrophy, compression fractures vertebral bodies, spondylolisthesis, trauma

Symptoms depend nerve roots affected: discomfort while standing, discomfort in shoulder/ arm/ hand cervical and lower limb for lumbar, bi,arterial symptoms 70%, numbness at or below stenosis, neurogenic claudication

70% stay same with time.

Question 7

Neurogenic claudication what, symptoms, cause, relief

Answer 7

(Pseuodoclaudication) symptom - pain or pains and needles in legs on prolonged standing and walking radiating sciatic distribution

Compression spinal canal stenosis -> venous engorgement of nerve roots during exercise-> reduced arterial inflow & transient arterial ischaemia -> pain/ paraesthesia

One or both legs, relieved rest/ change in position/ flexion spine

Question 8

Spondylolisthesia what, symptoms

Answer 8

Anterior displacement of vertebra Above on vertebra below. Many causes and classifications.

May gross instability of vertebral column, some asymptomatic, most some discomfort occasional lower back pain- incapacitating mechanical pain, sciatica, neurogenic claudication

Question 9

Lumbar puncture

Answer 9

Withdrawal fluid from subarachnoid space of lumbar cistern, diagnosis CNS disorders including meningitis and multiple sclerosis

Lying on side, back and hips flexed (knee to chest), skin covering lower lumbar vertebra anaesthetised-> lumbar puncture needle inserted midline between spinous processes of L3/4 or L4/5
. Located by finding plane transecting the highest points of iliac crests (supracristal plane) . Pass 4-6cm needle pops through ligamentum flavum-> punctures dura and arachnoid-> enters lumbar cistern, when stylet removed CSF escapes and collected