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Musculoskeletal System > Degeneration, Lower Back Pain and Disc Prolapse > Flashcards

Degeneration, Lower Back Pain and Disc Prolapse Flashcards

1
Q

What are the common types of lower back pain?

A 
Spondylogenic
Neurogenic
Viscerogenic
Vascular
Psychogenic
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2
Q

Give some examples of causes of lower back pain

A 
Mechanical back pain 
Disc herniation
Muscle strain
Ankylosing spondylitis 
IBD
Pyogenic sacroiliitis 
Herpes zoster 
Lymphoma
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3
Q

What is the most common type of back pain?

A

Mechanical

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4
Q

What are the features of mechanical back pain?

A

Positional
Activity may help
May have associated thigh pain

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5
Q

Where is mechanical back pain managed?

A

In primary care

  • reassurance
  • explanation
  • simple analgesia regularly

Physiotherapy if it fails to settle
Can consider alternative therapy

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6
Q

What percentage of mechanical back pain settles within 6 weeks?

A

90%

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7
Q

What percentage of mechanical back pain recurs?

A

60%

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8
Q

What percentage of people will suffer from back pain in their lifetime?

A

80%

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9
Q

What is the cost of back pain to the NHS?

A

£900 million

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10
Q

What percentage of GP referrals to orthopaedic outpatient clinics does back pain account for?

A

21%

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11
Q

What percentage of all NHS costs does back pain account for?

A

1%

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12
Q

What physical movements are important in relation to back pain?

A

Bending and lifting

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13
Q

How can back pain be managed generally?

A

Discourage the idea that it is a disease
Encourage general fitness - daily activity, reduce weight
Avoid activities that cause problems e.g. bending over, twisting, smoking
Understand the psychology
Understand the pathology

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14
Q

What structures can become diseased and result in back pain?

A 
Skin
Fascia
Fat
Muscle
Ligaments 
Tendons
Discs
Bone
Dura
Nerves
Abdominal contents
Vessels
Joints
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15
Q

What is the management for persistent back pain?

A

Rehabilitation programme
Pain clinics
Surgery very rarely indicated

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16
Q

What are the red flag symptoms of lower back pain?

A 
Age of onset < 20 or > 55
Recent history of violent trauma
Constant, progressive, non-mechanical pain
Thoracic pain 
PMH of malignancy 
Prolonged use of corticosteroids 
Drug abuse
Immunosuppression 
HIV 
Systemic illness
Unexplained weightless 
Widespread neurological symptoms 
Structural deformity 
Fever
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17
Q

What type of joint is at the intervertebral discs?

A

Secondary cartilaginous

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18
Q

What is the largest avascular structure in the body?

A

Intervertebral disc

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19
Q

What is the annulus fibrosis?

A

Tough outer layer of the intervertebral disc

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20
Q

What is the nucleus pulposus?

A

Gelatinous core of intervertebral disc

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21
Q

What damage can occur to the annulus and nucleus?

A

Annulus might tear
Nucleus might prolapse

Both can cause cord/nerve root compression

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22
Q

Where does the cartilaginous end plate of each intervertebral disc attach to?

A

The body endplate of the vertebra

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23
Q

How do the fibres of the annulus fibrosis run?

A

Obliquely and alternately between layers

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24
Q

What do the fibres of the annulus fibrosis resist?

A

Rotational movements

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25
Q

With what movements do discs fail?

A

Twisting movements

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26
Q

What does the nucleus pulpous consist of?

A

Water (88%)
Collagen
Proteoglycans

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27
Q

In what direction do disc prolapses usually occur?

A

Posterolateral

28
Q

What are the normal changes in the intervertebral discs associated with normal ageing?

A

Decreased water content
Disc space narrows
Degenerative changes on x-rays and in facet joints
Aggravated by smoking etc.

29
Q

What is the pathology of intervertebral disc herniation?

A

Tearing of annulus fibrosis and protrusion of the nucleus
Nerve root compression by osteophytes
Central spinal stenosis
Abnormal movement - spondylolysis, spondylolisthesis

30
Q

In what directions can lumbar disc prolapse occur?

A

Lateral - compressed nerve root

Central - compressed roots with caudal equina syndrome

31
Q

What are the features of nerve root pain?

A 
Fairly common 
Limb pain worse than back pain 
Pain in a nerve root distribution - radicular 
Root tension and root compression signs 
Dermatomes and myotomes affected 
Most settle in 3 months (90%)
32
Q

What is the treatment of nerve root pain?

A

Physiotherapy
Strong analgesia
Referral after 12 weeks
Imaging

33
Q

What disc problems can occur?

A

Bulge - common, mainly asymptomatic
Protrusion - annulus weakened but still intact
Herniation - through annulus, but in continuity
Dequestration - desiccated disc material free in canal

34
Q

What cervical level is most commonly affected by disc problems?

35
Q

What thoracic level is most commonly affected by disc problems?

A

Mid to lower levels T8-T12 75%
Most at T11/12

Thoracic < 1% of intervertebral disc prolapses

36
Q

In what directions can thoracic discs herniate?

A

Central
Posterolateral
Lateral

37
Q

What lumbar level is most commonly affected by disc problems?

A

Usually L4/5 (45%)
Followed by L5/S1 (40%)
Then L3/L4 (10%)

38
Q

In what direction do most disc herniations occur in the lumbar region?

A

Posterolateral

39
Q

What are the features of cervical and lumbar spondylosis?

A

Common
Degenerative changes at facet joints and discs
If severe, can compress the whole cord, not just the nerve roots, causing myelopathy
UMN signs in limbs e.g. increased tone, brisk reflexes

40
Q

What part of the cervical spine transmits the vertebral artery?

A

Foramen transversarium

41
Q

What cervical vertebrae do not have a bifid spinous process?

42
Q

What is C7?

A

The vertebra prominens, first easily palpable spinous process

43
Q

Why might the patient lose consciousness in cervical spondylosis?

A

The vertebral artery passing through the foramen transversarium may get nipped/occluded

44
Q

What movements do the facet joints of the lumbar spine mainly allow?

A

Flexion and extension

45
Q

What do the intervertebral discs allow movement between?

A

Between the vertebrae

46
Q

What are the main ligaments of the spine?

A 
Anterior longitudinal ligaments 
Posterior longitudinal ligament 
Ligamentum flavum
Interspinous and supraspinous ligaments
Intertransverse ligament
47
Q

What is cauda equina syndrome caused by?

A

Compression of the cauda equina, usually due to herniated lumbar disc

Can also be caused by tumours, trauma, spinal stenosis, epidural abscess and iatrogenic causes

48
Q

What are the clinical features of cauda equina syndrome?

A

Injury or precipitating event
Location of symptoms - bilateral buttock and leg pain, varying dysaesthesia and weakness
Bowel or bladder dysfunction - urinary retention +/- incontinence overflow
Saddle anaesthesia, loss of anal tone and anal reflex
High index of suspicion in post-op spinal patients with increasing leg pain in presence of urinary retention

49
Q

What radiography should be done if suspecting cauda equina syndrome?

A

MRI

Lumbar CT or myelogram if MRI is contraindicated

50
Q

What is the treatment of cauda equina syndrome?

A

Operative, within 48 hours

51
Q

What does spinal claudication need to be distinguished from?

A

Vascular claudication

52
Q

What are the features of spinal claudication?

A

Usually bilateral
Sensory dysaesthesia
Possible weakness, foot drop and tripping
Takes several minutes to ease after stopping walking
Worse when walking down hills, better when walking uphill or riding a bike

53
Q

Why is spinal claudication worse when walking downhill?

A

The spinal canal becomes smaller in extension

54
Q

What are the types of spinal stenosis?

A

Lateral recess stenosis
Central stenosis
Foraminal stenosis

55
Q

What is the treatment progression of lateral recess stenosis?

A

Non-operative
Nerve root injection
Epidural injection
Surgery

56
Q

What is the treatment progression of central stenosis?

A

Non-operative
Epidural steroid injection
Surgery

57
Q

What is the treatment progression of foramina stenosis?

A

Non-operative
Nerve root injection
Epidural injection
Surgery

58
Q

What is spondylolysis?

A

Defect of pars interarticularis

59
Q

What is spondylolisthesis?

A

Anterior vertebral translation of cephalad vertebra on caudad vertebra

60
Q

What are the features of spondylolysis?

A

Low back pain

Occasionally radicular symptoms

61
Q

What investigations are done for spondylolysis?

A

CT
MRI
Bone scan

62
Q

What is the treatment of spondylolysis?

A

Non-opertive
Injection therapy
Surgery

63
Q

What are the features of spondylolisthesis?

A

Symptoms vary with type

Treatment depends on symptoms - conservative, lifestyle changes, surgery for persistent pain +/- nerve root entrapment

64
Q

What is the radiographic (Meyerding) classification of spondylolisthesis?

A 
Grade 1 - 0-25%
Grade 2 - 25-50% 
Grade 3 - 50-75%
Grade 4 - 75-100% 
Spondyloptosis - body of L5 vertebra sitting in front of S1
65
Q

What is the aetiological (Wiltse) classification of spondylolisthesis?

A 
Congenital 
Isthmic 
Degenerative
Traumatic 
Pathological

Musculoskeletal System (40 decks)

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