Cortex - adult orthopaedics spine and upper limb 1 (spine)

Question 1

What is the cause of most cases of back pain ?

Answer 1

Mechanical back pain

Question 2

Describe the presentation of mechanical back pain

Answer 2

Thought of as recurrent relapsing and remitting back pain with no neurological symptoms.

Pain is worse with movement (mechanical) and relieved by rest

Question 3

What is the typical patient with mechanical back pain ?

Answer 3

Between the ages of 20-60 and have had previous flare up. No red flags

Question 4

What are some of the causes of mechanical back pain ?

Answer 4

• Obesity
• Poor posture
• Poor lifting technique
• Lack of physical activity
• Depression
• Degenerative disc prolapse
• Facet joint OA and spondylosis.

Question 5

What is the mainstay of treatment of mechanical back pain ?

Answer 5

Analgesia and physiotherapy. (not rest as will lead to stiffness)

Question 6

In an acute intervertebral disc tear what part it torn ?

Answer 6

The outer annulus fibrosis

Question 7

How do acute disc tears classically occur ?

Answer 7

After lifting a heavy object e.g. a lawnmower

Question 8

What is the back pain in acute disc tears characteristically made worse by ?

Answer 8

Coughing

Question 9

What is the treatment of acute disc tears ?

Answer 9

Analgesia and physiotherapy are the mainstay of treatment.

Question 10

What is a potential complication of acute disc tears ?

Answer 10

The inner gelatinous nucleosis can herniate or prolapse through the tear and press (impinge) on an exiting nerve root

Question 11

What are some of the signs that an acute disc tear has started to impinge nerve roots ?

Answer 11

• Pain
• Altered sensation in a dermatomal distribution as well as reduced power in a myotomal distribution.
• Reduced reflexes and motor function (LMN lesion)

Question 12

What is the most common site in the spine for disc impingement to occur ?

Answer 12

L4, L5 and S1 nerve roots contributing to the sciatic nerve

Question 13

Go over the route of spinal nerves (this will help you determine what spinal nerve route is impinged with different types of proalpses)

Question 14

What is sciatica ?

Answer 14

Radicular pain felt as a neuralgic burning or severe tingling pain, often like severe toothache radiating down the back of the thigh to below the knee. (Note back pain can radiate to the buttock and thigh but not below the knee).

Question 15

What is the first line treatment of sciatica/lumbar radiculopathy ?

Answer 15

Analgesia, maintaining mobility and physio

Question 16

What can be added second line for more sever sciatica/ lumbar radiculopathy ?

Answer 16

Drugs for neuropathic pain (eg Gabapentin)

Question 17

What can cause bony nerve root entrapment ?

Answer 17

OA of the facet joints can result in osteophytes impinging on exiting nerve roots

Question 18

What is bony nerve root entrapment basically the same as in terms of symptoms ?

Answer 18

Herniation/prolapse of intervertebral discs esulting in nerve root symptoms and sciatica as previously discussed.

Question 19

What is a potential treatment of bony nerve root entrapment ?

Answer 19

Surgical decompression, with trimming of the impinging osteophytes in sutiable candidates

Question 20

What is spinal stenosis and its causes ?

Answer 20

It is an abnormal narrowing of the spinal canal - reducing the space the cauda equina has

Can be cuase by:

Spondylosis and a combination of bulging discs, bulging ligamentum flavum (ligaments of the spine connecting adjacent laminae of vertebrae) and osteophytosis

Question 21

What is the characteristic presentation of spinal stenosis ?

Answer 21

Sufferers tend to over 60 and characteristically have claudication (pain in the legs on walking).

Question 22

What is the difference in claudication due to spinal stenosis rather than PVD?

Answer 22

• Claudication distance is inconsistent
• The pain is burning (rather than cramping)
• Pain is less walking uphill (spine flexion creates more space for the cauda equina)
• Pedal pulses are preserved

Question 23

What is the treatment of spinal stenosis ?

Answer 23

• 1st line - conservative management with physiotherapy and weight loss
• 2nd line - surgery may be performed (decompression to increase space for the cauda equina)

Question 24

What is cauda equina syndrome and the affected nerve roots ?

Answer 24

It is where a very large central disc prolapse occurs which compresses all the nerve roots of the cauda equina

Affected nerve roots include the sacral nerve roots (mainly S4 & S5 but variable and others contribute) controlling defaecation and urination.

Question 25

What can prolonged compression in cauda equina syndrome result in ? (hence why it is a surgical emergency)

Answer 25

Can potentially cause permanent nerve damage requiring colostomy and urinary diversion

Question 26

What are the key symptoms/signs of cauda equina syndrome ?

Answer 26

• In essence, any patient with bilateral leg symptoms/signs (saddle anaesthesia) with any suggestion of altered bladder or bowel function is a cauda equina syndrome until proven otherwise.
• Bilateral sciatica
• Decreased anal tone

Question 27

What are the 2 main investigations which must be done when suspecting cauda equina syndrome ?

Answer 27

A rectal PR examination

Urgent MRI to determine the level of prolapse

Question 28

What is the treatment of cauda equina syndrome ?

Answer 28

Urgent disectomy (believe this is the surgical technique for impingement type stuff if surgery is required)

Question 29

Usually in the lumbar spine, the nerve root corresponding to the lower of the two vertebra in the affected segment is compressed (by disc prolapse or bony entrapment), what is the typical pattern of signs/symptoms for:

1. L3/4 prolapses
2. L4/5 prolapses
3. L5/S1 prolapses

Answer 29

1. L3/4 prolapse ==> L4 root entrapment ==> pain/loss of sensation in medial aspect of leg to med malleolus (L4), loss of quadriceps power, reduced knee jerk
2. L4/5 prolapse ==> L5 root entrapment ==> pain/loss of sensation down dorsum of foot and lateral leg, reduced power Extensor Hallucis Longus (dorsiflexion of big toe) and tibialis anterior. Reflexes intact.
3. L5/S1 prolapse ==> S1 root entrapment ==> pain/loss of sensation to sole and lateral aspect of foot, reduced power planarflexion, reduced ankle jerk reflex.